The day I was diagnosed with mild bipolar disorder, I wasn’t feeling particularly bad. I had been taking an antidepressant for a couple of years, and it had made what ranged from generic ennui to immutable, confusing depressions—perhaps also generic, though feeling like anything but at the time—recede into the background of a life rich with family, friends, parties, and work. Life hummed along nicely until a summer trip to Majorca, where, on vacation in a small stone house overlooking an olive grove, I lost grasp of the good feeling, sleeping immensely long hours and withdrawing from conversation. Joy in the present fizzled in the proverbial bell jar. Three weeks later, after a sluggish return to Manhattan, a period during which I rarely changed out of sweatpants, I awoke one morning to my heart pounding in my ears and the sunlight that had poured through the shutters every other morning to no effect now invigorating me to the core. In the days that followed, I began to feel well again, perhaps better than well.
This is the point in the bipolar story at which you’re supposed to book a first-class ticket to Paris and spend $30,000 in one weekend at the Plaza Athénée. Or look on amazed, or terrified, as the sunlight metamorphoses into a band of descending seraphim. Or systematically begin to date all 525,003 men in your Friendster personal network. But the reality is that nothing of the sort happened—I simply felt smarter, funnier, cooler, prettier, better than I had before. I had fabulous concentration, was undistracted by any edge of competition or envy, and found that I could function easily on five or six hours of sleep. I went out to parties often, dressed in tight fuchsia tops and barely there miniskirts. No one was saying no to me; “no” was not an acceptable answer. One time I broke a heel off at a nightclub at 2 a.m., and when I took a taxi back to my apartment ten blocks away to change into another pair of shoes and the cabbie wouldn’t wait while I ran upstairs, I called the police on my cell phone. We pitted wits in the idling cab for 25 minutes until they arrived. (The gracious, though quizzical, cops let the driver go, then waited for me to change and escorted me back to the club.)
So it came as something of a shock when, on a semi-annual visit to my psychopharmacologist, the clever one whose shelves were stacked with Celexa mugs and an extensive teddy-bear collection—who is the crazy one here?—I was informed that this behavior was not only immature but perhaps also a symptom of a madness associated with Romantic poets, a bullfight-obsessed writer, an artist who cut off his ear. All at once, what I had considered garden-variety depression was recast as something far more sinister and mysterious, a balance beam of an illness where the upper pole was as much at issue as the lower. My ups were now called hypomania, marked by less sleep, less patience, more travel, more creativity, more talking, more narcissism, more sex, and more shopping. With hypomania, one might engage in “excessive involvement in pleasurable activities with a lack of concern for painful consequences,” as well as inappropriate laughing and joking, and, as one set of diagnostic criteria had it, “inappropriate punning,” a behavior I hoped I had never exhibited, though I had my fears. One might also have a certain temperament, characterized by a tendency for attention-seeking, coupled with a nagging fear of being noticed. An impulsivity that alternated with a fear of acting on what spontaneity had sowed. An inflated sense of self-importance combined with profound feelings of neediness.
I couldn’t argue with that.
As much as depression was the illness of nineties, mild bipolarity has become the new diagnosis for a slice of society that includes hard-to-treat depressives and some with a personal disposition that perhaps hedges into ordinary moodiness. Actually, many doctors believe that the widespread prescription of antidepressants over the past decade has been instrumental in uncovering, and even exacerbating, bipolar conditions. “As more and more people are taking antidepressants, more and more bipolarity is being exposed, because anyone who becomes hypomanic on antidepressants is bipolar,” says Ivan Goldberg, a psychiatrist with offices on the Upper East Side. “You look into their family history, and you almost always find an uncle, a grand-uncle, a parent who was irritable, irascible, and impossible—just plain difficult—and they were bipolar. Bipolarity has been thought of as a rare illness, but it’s actually a common one.” There’s even a separate diagnostic category for bipolar patients whose condition has been triggered by antidepressants: bipolar III. Says Joseph Goldberg, director of the Bipolar Disorders Research Program at the Zucker Hillside Hospital: “These patients don’t just listen to Prozac—they really listen to Prozac.”
Bipolarity, called manic-depression until the mid-twentieth century, has traditionally been considered not only a unique disease but also an awful one, involving an expansive kind of madness suited to creative achievement and personal chaos. Part of the mythology of the illness is that it tends to affect visionaries, like Shelley, Coleridge, and Blake, or flamboyant personalities—like Ted Turner, Jim Carrey, and Carrie Fisher, whose new fictionalized memoir, The Best Awful, deals with her battle with the condition. That there could be vast shades of bipolarity is a notion that was common at the turn of the last century but with little clinical currency in this one until recently. Nowadays, academic researchers have started to speak confidently of a “bipolar spectrum.” It’s a rainbow that includes highly functional people as well as those with powerful psychoses, some substance abusers, borderline-personality-disorder cases, and kids and adults with attention-deficit/hyperactivity disorder. Some doctors have even suggested renaming classical bipolarity “Cade’s disease,” after the first scientist to recognize the anti-manic qualities of lithium, thus effectively cutting full-blown mania out of the bipolarity picture.
Part of the spectrum is elucidated in the current edition of the DSM, the diagnostician’s bible: bipolar II, depressive periods alternating with at least four days of hypomania; cyclothymia, rapid cycles of mild lows and mild highs each lasting a few days, with few normal periods in between; and a category called bipolar “not otherwise specified.” Now psychiatrists talk not only about bipolar III, bipolarity triggered by antidepressants, but also other gradations of the illness, like bipolar IV, an agitated depression that predominantly affects people over 50 with “extroverted personalities that are sometimes, in my view misleadingly, described as ‘narcissistic,’ ” according to Hagop Akiskal, professor of psychiatry at the University of California, San Diego.
The psychiatric community is split on this expanding palette of diagnoses. “The heart of the controversy is that a lot of clinicians throw rigor out the window when they assume that any patient with irritability and mood symptoms automatically has bipolar disorder,” says Joseph Goldberg. “It’s fair to ask the question as a kind of hypothesis, but it remains a clinical diagnosis, without laboratory tests to validate it, and it can be overdiagnosed.”
Though the official incidence of bipolarity in the U.S. population is estimated at 1.2 percent, a survey published in the Journal of Clinical Psychiatry in January 2003 found that 3.7 percent of the population might be bipolar in one form or another (and some doctors argue that even that figure is low). In that study, 80 percent of those who exhibited bipolar tendencies had not been diagnosed, and nearly one-third had been misdiagnosed with “unipolar” depression. Just under 10 percent of all 18-to-24-year-olds surveyed screened positive for the illness. “The incidence of bipolarity isn’t a matter of opinion,” says Myrna Weissman, professor of psychiatry and epidemiology at Columbia University. “It’s a matter of evidence.”
It’s a well-established fact about medicine that new diagnoses often appear in chicken-and-egg tandem with new drugs, and the new family of bipolar disorders may be no exception. “In some ways, what’s been happening is like what happened with Prozac, in that finally we had something to treat with that wasn’t as bad as the disorder itself,” says Terence Ketter, head of the Bipolar Disorders Clinic at Stanford University. Since lithium, the onetime wonder drug of bipolarity, has no patent protection, there’s an upside in the mood-stabilizer market. The last year has seen a spate of FDA indications of atypical antipsychotics for bipolar episodes, like Risperdal and Seroquel, as well as the marketing of a new drug, Symbyax, a combination of Prozac and the atypical antipsychotic Zyprexa, to be prescribed for bipolar depression.
The most important new drug for mild bipolarity is Lamictal, the anticonvulsant that, last summer, became the first drug since lithium approved by the FDA for the long-term treatment of bipolar disorder. “Just as lithium’s advent caused more attention to bipolar I, Lamictal’s advent will probably bring more attention to bipolar II,” says Dr. Frederick Goodwin, co-author of the definitive text Manic-Depressive Illness. “In its own way, the best patient group for Lamictal therapy is the bipolar II patient, a person with mild manias and severe depressions.” The side effects are also more tolerable than those of any bipolar drugs: little weight gain, lethargy, or nausea. “It’s the most interesting drug to come along since lithium,” says Ivan Goldberg. “Lamictal is hot shit.”
A bellwether of the expanding bipolar diagnosis is Andrew Solomon, the New Yorker writer whose book The Noonday Demon explored the history of depression and his own relationship to the illness. His psychiatrist suggested he might be bipolar II several months ago. “When I was told, I almost felt cheered up by it—Maybe now we’ll solve the mystery, I thought,” says Solomon. “It made sense: When I’m at what I think of as my best, I’m kind of manic; I think I can do anything, I rule the world, I can win the Nobel Prize.” Jessica Lynch, Miss New York, a depression advocate, and no relation to the POW, was rediagnosed as bipolar recently as well. “I thought about a time where I was spinning around the room laughing and goofing around, laughing inappropriately, I guess, and I almost stepped on my laptop computer, which was on the floor,” she says. “I just kept laughing. That up mood lasted a few days, and then it went away.”
“A doctor said to me, ‘if you don’t have problems with shopping or sex, you’re not bipolar, period,’ ” says Christine, an interior designer.
Mild bipolarity, after all, can be an illness of subtle signs. “You get to know your patient very well,” says Frank Miller, a psychiatrist with a prim office on Fifth Avenue in the Sixties, the perfect reflection of an ordered, genteel mind. He is in his late fifties, wearing a well-tailored navy suit, with round eyeglasses and a slight physique that give him the look of an elder Harry Potter. “You see that their depression gets better. You see a period of normal. And then, quite unexpectedly, whether it’s a year later or six months later, a person comes in a little more dressed up, a woman maybe in a dress that’s too short, a lipstick too widely applied, a kind of spontaneity, a spunkiness that you’ve just never seen before. It only lasts for a week, and then all of a sudden, they’re depressed. That person could easily be reconceptualized as a bipolar individual, although that is the totality of the hypomania that you’d see: four or five days, quite subtle, and not recognized by family, friends, or colleagues as evidence of anything extreme. But there it is: a third mood, so to speak.”
Miller sees bipolarity as a distinctively New York phenomenon. “It may very well be that the frenetic, kinetic lifestyle of a major urban center like New York in the 21st century could be provoking more people to manifest their bipolar vulnerability than we have seen in any preceding century,” he says. “It may very well be that the world you’re living in is not a world of 1-in-120 bipolarity. The people you know in this city are people who are coming from all over, people with energy and excitement and stamina, and it may be in this city, in the people that you find yourself knowing, with throwing in other factors—staying out late, the bar scene, marijuana, being at places where people with bipolar are likely to congregate, differentially—then maybe it’s 1-in-8 that the people one actually hangs with have bipolar risk.”
He crosses his hands in his lap. “I have a patient who works at Lotto,” he says, “and she is intrigued by how many people win the lottery.”
A third mood that is a mood of ebullience, enthusiasms, and creativity is not something that’s usually considered problematic, and certainly not something that one wants medicated away. Hypomania is heightened experience—a drug you want more of. One is fascinated by the world, and sometimes it seems that the world falls in love with you, too, turning all the lights up Sixth Avenue green, sending the subway rushing into the station a moment after you’ve swiped a MetroCard. This can seem to be your best self, the state of self-actualization that one prays to get to with self-exploration, therapy, and medication, but for many remains just out of reach.
Hypomania’s hallmarks—shopping sprees and sexual promiscuity are the classics—aren’t exactly behaviors foreign to many of us, and are in fact what’s considered by some to be fun. (“After I was diagnosed as bipolar II, I ran around to a bunch of doctors for second opinions, and one of them said to me, ‘If you don’t have problems with shopping and sex, you’re not bipolar, period,’ ” says Christine, a 33-year-old interior designer.) A friend, a best-selling author and screenwriter in his fifties who was diagnosed as mildly bipolar a few months ago—bipolar IV?—says that when he asked his doctor why he was experiencing what was understood as his first mania so late in life, the doctor suggested that his “wonderful wild years of promiscuity with guys in the seventies was an eight-year mania.” He sighs. “I mean, I don’t know. I was at Studio 54 every night for two and a half years. I went to the baths all the time, but everybody did. I saw my lawyer there every day.”
Personally, I’d never thought of my symptoms as “symptoms,” unusual though they sometimes seemed. Many people dealing with a bad breakup might cry in the tub for a couple of weeks—even months—but eventually return to their normal life. When this happened to me, however, I, in the course of a week, sublet my apartment, packed up my belongings, and took off to Southeast Asia for three months. Hypomania? Possibly. Fun? Definitely.
For another, there was the fact that I am an excitable person. I’d always thought that my explosive outbreaks, usually directed at some unsuspecting member of the service class, particularly if he happened to work for my cell-phone provider, were a release valve for a stressed life, or at least understood them as depression turned outward, as any lay psychologist would. If a construction worker whistles at me on the street, I give him the finger; the other day, I was walking through Tribeca when a truck driver screamed some hideous profanities at me out his window, and I got so angry I tried to pick up a garbage can and throw it at the cab of his truck (I’m five foot two and 105 pounds—lifting the can wasn’t a realistic expectation).
But what if this kind of slight mania, this volatility and exuberance, is not a gift but a symptom? “The distinctions between hypomania and a state of exuberance can get very blurred,” says Kay Redfield Jamison, a professor of psychiatry and author of several key manic-depressive texts, including a memoir of her own experience with the illness, An Unquiet Mind. “Exuberance—high energy, high mood, ebullience—is very understudied and extremely underappreciated as a vital emotion. It’s tied up with curiosity, adventure, and scientific discovery; it’s getting reignited when you would otherwise fall over; it’s adaptive. But hypomania, when it’s associated with depression, the worsening course of a disease, increased alcohol and drug use, financial ruin, or constant emotional turmoil—none of those things are adaptive. It’s easy to romanticize a pathological state, to say this is the result of a very romantic temperament. Certainly, in my own life, I spent a long time saying ‘This isn’t so bad,’ and nearly died because of it.’”
For Jamison, hypomania meant thinking that she could go off her medications—which led to mania, psychosis, and attempted suicide (bipolarity has one of the highest suicide rates of all mental illnesses—a remarkable 10 to 20 percent of unmedicated bipolar patients, as estimated by the National Institute of Mental Health). “The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity,” she writes, in An Unquiet Mind. “Everything previously moving with the grain is now against—you are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of the mind. You never knew those caves were there. It will never end, for madness carves its own reality.”
“I want to get my nosed pierced, but my doctor doesn’t want me to,” says a 26-year-old banker. “Is this manic? Or am I lightening up a bored life?”
These caves are a place that mild bipolar patients hope never to visit, though there is always the chance. “For ten years, I was told I had dysthymia—mild depression—and now I feel like one of them,” says a fashion-editor friend of mine, who was diagnosed as bipolar last year, at 36, after a heady pregnancy (“I was eight months pregnant, decorating a new apartment, running to Chelsea and hoisting plants into cabs”) followed by a severe postpartum depression. “I’ve heard about bipolar people running naked through the night, and they don’t know who they are or where their shoes are. I’m like, ‘Is this what’s in store for me? Am I going to get worse?’”
If one does not go on a mood stabilizer, say psychiatrists, there is a possibility of “kindling” the hypomania, a two-sticks-rubbing-together concept borrowed from the etiology of epilepsy, whereby applying a low-threshold stimulation to a particular part of the brain, repetitively, eventually causes that part of that brain to have spontaneous electrical activity, or seizures. In the same way, there is some evidence that repetitive mood episodes might lead to the development of more frequent, more spontaneous, and more manic moods, and hypomania as a harbinger of that is far less appealing.
“I find this ‘kindling’ thing the most horrible concept,” says a friend. “I’m so nervous—I was going to have a colonoscopy, and I didn’t do it, because I was worried that with the stress I’ll be kindled! I got a leak in my ceiling: I’m going to be kindled!”
The person who sat on the couch the snowy day that my psychopharmacologist prescribed a new regimen of medications was far from kindled; in fact, I was getting more depressed by the minute as I was briefed on the benefits and side effects of each new medication, gathering a little clump of white slips that put me solidly out of the world of dysthymia, the world where you take one antidepressant and wonder sometimes if you even need that. Since there was some concern that Zoloft could be “kindling” my hypomania, I was to stop it immediately, but it would take a while to introduce Lamictal into my system—if it is not taken in bit by bit, by about 25 milligrams a week, one can develop a fatal rash (a fatal rash? This was getting creepy). So I was supposed to shift to Wellbutrin, a milder antidepressant that I could tolerate without cycling, and Neurontin, an anticonvulsant. I also had Ambien, for insomnia, and Xanax, for anxiety. Anxiety was, of course, what was produced when I lined up all those little bottles on my kitchen counter. Now that I had the drugs, I didn’t take them. In fact, I did little more than peer tentatively into the bottles for a few months. (My psychopharmacologist informed me that this, too, was likely a symptom.)
Like any subculture, subtle bipolars had a significant presence on the Internet, and I soon became addicted to mood-disorder bulletin boards, scrolling through messages with subject lines like “That Bitch Bipolar II” or “Update on My Broken Brain and Its Treatment” late into the night. I’d wondered what tribe it was that I’d joined: The talk always seemed to be about “meds” or “pdocs,” with a disproportionate emphasis on pinning down one’s exact diagnosis, often rendered in a shorthand, like “mild bipolar, OCD tendencies, inattentive ADHD.” The language that people used to describe their emotions sounded eerily similar to the criteria for their diagnoses listed in the DSM—who describes themselves as irritable or hypersexual?—and that weird semantic smoke screen made it hard to relate. It wasn’t exactly the cave described above, but it wasn’t a place I wanted to linger.
The Mood Disorders Support Group, which met on Friday nights at Beth Israel Medical Center, brought real people with these problems into my life. It was still strange to break bread with people who had been hospitalized, more than once, or the pixie with black pigtails who kept nine medications in her handbag, pulling them out one by one to expound upon the benefits, and stranger still when I realized how distinctly some people’s moods shifted from week to week, sometimes black, sometimes benign. But there were also some people there who sounded familiar, in particular a 26-year-old banker, a graceful Indian-American woman with long black hair and onyx eyes that didn’t seem so much to give off light as refract it. She was energetic, and talkative, and sincere; she had been diagnosed over the summer, during what she thinks was a four-month period of mania, which was followed by a four-month depression, and now, according to her psychiatrist, she was in a mixed state, experiencing the agitation of hypomania coupled with the emotions of depression. “I want to get my nose pierced, but the doctor says that he doesn’t want me to do it in a mixed state,” she said, at an East Village tea salon after the group meeting. “It’s like, ‘Is this manic? Or am I just trying to lighten up a bored life? Dude, I want a little excitement—I’ve spent the last four months depressed.’ ”
Life was going well before, for the most part. “On paper, I’m perfect: went to a nice private school, graduated from Wharton with two degrees, on a fast track to private equity or a hedge fund. Look, I was in tech in 2000—it wasn’t an easy thing to be doing. I was going to be the first one of my friends to make a million.” Somewhere along the line, though, she got confused. “I was hypersexual—I needed to have sex every day, and if I was drunk, you could get me to do anything. My boyfriend liked it, too, by the way. I went to Vegas and I was in a boutique at the Hard Rock, and this guy said he’d buy a thong for me if I’d model it for him, so I did. Now I look at that thong and I think I’m a slut. But at the time it seemed like a fun thing to do.”
The last month or so had been particularly rough: She felt angry and sad all the time. “I’m sorry to say I like the idea that there’s something wrong with me that’s not my fault,” she said. “I’m allowed to wallow in pity. I didn’t ask for this—this BP Express came to me. Now I see everything as a product of being bipolar, the result of an uncontrollable disease. My anorexia, my drinking, my OCD things like counting steps, were masking the bipolarity—all attempts to control the mania. I thought I had a bunch of different problems, but it turns out that the root cause is one.” She took a sip of her water—she ordered only water. “Right now, I don’t want to be black or white, zero or 100. I want to be gray. If that’s a numbed-out version of a fun person, that’s what I’ll be.”
The Indian-American banker was certain about who she was, and who she wanted to be. But I was much less so. And others had their own questions about the new diagnosis. “There are certain fads that take off, and the current one is bipolar II,” says Howard Smith, director of operations for the Mood Disorders Support Group. “A few years ago it was schizoaffective disorder. Then it was borderline personality disorder. Next year it will be something else. It’s not that doctors don’t know what they’re doing: They’re responding to patients. Patients press doctors for labels. And doctors want to keep you on your meds, so they’re okay with it.”
Doctors, and meds, play some role, though. “The fact is that if you have a lot of treatment options for something, you’re more inclined to want to diagnose it,” says Joseph Goldberg. “By analogy, if I have many treatments for depression but very few for dementia, and the two diagnoses are often hard to differentiate, I would sure prefer that my patient had depression. And I might even treat him as though he had depression, because it’s easier to treat than dementia. But that’s not a scientific way of deciding whether a diagnosis exists. So there’s some thinking here of, ‘Might this fall in the bipolar spectrum, and because there are so many medicines now to treat that thing, should we try one out?’ ”
Andrew Solomon, for one, has looked at life through many different medications. “You get to a point where you’ve been through so many changes or chemical selves that you think, Okay, we’ll try another bunch of chemistry and see who I turn into,” says Solomon. “What I really hoped was that if I got a new diagnosis, I’d get some new treatments, and maybe I would feel wonderful all the time. But that didn’t happen. So the clarity I hoped would come with that diagnosis of bipolar II has not been forthcoming—my experience has been maybe it’s bipolar II, maybe it’s depressive.” Over the Christmas holidays, in fact, Solomon relapsed into a major depression. “At this point, I would be happy to take mood stabilizers if they seemed appropriate to my doctor; I’m taking an antipsychotic, even though I’ve never been psychotic,” he says. “Unfortunately, the way you deal with these things is you take 27 medications, and if they don’t work, you try another 27. In some curious way, you disavow your authentic engagement with the idea that there is such a thing as a proper, stable, immutable self.”
As for myself, I spent months resisting the diagnosis, staring at my little shelf of pills. The medical Establishment had spoken, which is always a daunting thing. Still—was this, too, a symptom?—I kept wanting some hard evidence of my condition. “I wish there was a test,” I said at one support group. “There is no test,” said the girl in black pigtails, peering at me through her square designer glasses, “and if there was, I don’t think you’d take it.”
It took a period of plummet for me to begin the course of medications I had been prescribed. I worked the Lamictal into my system slowly, and I didn’t think much about the potentially life-threatening rash until I woke up one morning with a spray of pink bumps across my arms and neck. I didn’t have to wait long at the emergency room, and it didn’t take the doctor long to decide what to do: no more Lamictal.
I’d love to say that I did the responsible thing, heading back to the psychopharmacologist for a new batch of prescriptions. Instead, I called time-out. I began to see a new therapist, who saw drugs as a last resort and had no faith in my diagnosis. A long period of relative peace and happiness followed this renegotiation of myself, and the depression scared into corners by antidepressants seemed to lift in a more organic fashion, bit by bit. And now, I tend to believe that my interlude as a bipolar patient was the result of the perfect storm produced by a period of maturation colliding with an expanding diagnosis. Because afterward, without meds, there was no madness—there were only other relationships, other challenges, and other ways of growing, and with them, new risks, new experiences, new summits.
But maybe that’s the hypomania talking.
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