Musings: The Relationship Between Manic and Panic

I’ve been struggling with panic attacks recently, so obviously my first inclination is to figure out what the hell is going on in my brain. I went to the ER, talked to doctors on multiple occasions, and I still have no answers to solidly treat and explain my sudden onset of panic attacks. However, yesterday I was low on my regular lithium dose from not realizing the pharmacist accidentally shorted me; I found the panic symptoms yesterday (which seem to have been an almost daily occurrence) to be manageable without knocking myself out with medication.

But first thing’s first: Correlation does not equal causation. I got an idea in my head on why my panic symptoms were suddenly not a big deal, but it’s not based in solid evidence, so there’s my disclaimer. I can partially back it up, but only on a theoretical level — but hey, it might help someone out, so that’s why I’m writing this. The idea is that the neural mechanisms that allow manic symptoms to be activated could overlap with the neural mechanisms that contribute to panic symptoms in a way that dampens the panic symptoms. That will sound extremely vague to any neuroscientist out there; alas, I am not a neuroscientist, but I like to think I know a thing or two.

That might sound like I’m saying “just be manic and you won’t be anxious anymore!” Well, that’s true for a lot of people, but that’s also not a good idea — it’s just trading one evil for another. But perhaps there’s a fine line to be drawn here. The neurobiology of depression and anxiety seem to be increasingly similar, and if mania is the opposite in that way then maybe there’s a part of mania that can be isolated to treat those anxious, panic symptoms. It’s doubtful to work for everyone, but I’d almost wonder if slight hypomania could be part of the answer.

I don’t recommend changing your medication without your doctor’s approval, but I’ve come to the point in my treatment where my doctor asks me what medications I want to be on. So I made an executive decision to lower my lithium to, in theory, lower the blockade to those manic symptoms. I do this cautiously, as the last thing I want is to have a manic episode. Partner monitoring, blood tests, and self-monitoring are part of being responsible in this way; even the slightest medication change can have a big impact, so it’s important to have a safety net in place. My preliminary results suggest that I’m onto something, but it’s far too early to tell.

I’ve been taking 900mg of lithium SR for a while now, and when I ran out of meds I only had one 300mg pill to take. I noticed the difference when I woke up — the irritability mostly, but also the lack of concentration and the fantastic way music was sounding. After leveling at 600mg those symptoms are gone, but so is the awful anxiety that usually progresses into an out of body experience and feeling like I’m going to die. I really hope it stays that way, as I obviously don’t enjoy feeling like I’m on the verge of death and logic doesn’t help get me out. There’s certainly other factors to take into consideration, so I’ll update this post accordingly as I go through that list and observe these new changes.

ASTU 400L – Redefining Mood Disorders

In late 2013, I approached a professor, whose class I had taken during the summer, and I asked him if he would be the faculty sponsor for a course I wanted to run through the Student Directed Seminar (SDS) program at UBC. He agreed, and thus I worked for months on how to put together a class about mood disorders. It began out of a burning frustration with not understanding my own diagnosis of bipolar disorder. It ended with a vastly bigger understanding, a great group of students, and material that has the potential to affect how we view and treat mental health conditions.

There was no precedence for this material before at UBC. So there were a lot of road bumps we hit along the way, but we came out alive on the other side. I started by posing the following two questions to the group:

What is depression? January 6, 2015
What is bipolar disorder? January 6, 2015

What’s most significant to me is the change I saw reflected in ourselves from beginning to end. When the term was over, I put the same questions up on the board, and everyone sat in silence. It was a long silence. I went up to write first, and encouraged everyone to do the same, but they said they needed time to think — it wasn’t an easy answer, or perhaps there was no one answer at all. There were less answers than before.

2015-04-09 15.39.51
April 9, 2015

It’s not so simple anymore, is it?

Mood disorders are complex phenomena at best. With neuroscience being a budding field and the dawn of humanistic psychiatry still rising, it’s not surprising that stigma persists around these disorders. But what I find fascinating and quite heart-warming is the differences between these pictures. The change in the student’s thoughts and perceptions of depression and bipolar was dramatic, and I feel grateful in being able to witness such an evolution.

Having bipolar, I went into the class not knowing how everyone would react to when I eventually revealed myself and my goals in creating the class. I didn’t mention it until I found it necessary, about a couple weeks in, but from my perspective they took it in stride and with open minds. My main take away from this entire experience is how education can decrease stigma even in a short amount of time (the class ran throughout term 2, about three months meeting twice per week). What I found more intriguing is the comparison to the behaviour disorders class also taught at UBC. There seemed to be a general consensus on the poor quality of the behaviour disorders class in comparison to classes that looked at such disorders in more detail.

In the same amount of time my seminar was run in, that behaviour disorder class also runs. Except the latter goes through most of the psychiatric diagnoses. Having taken that course as well, I noted instances where the material presented was stigmatizing. For example, “bipolar patients” were stated to have poor quality of life overall. Research states otherwise. My writing this and having run an entire seminar states otherwise. Perhaps it was the professor, but this should not be overlooked in any case. Additionally, from the frustrated comments I received during my seminar I can conclude with certainty that even focusing on a subset of disorders in the same amount of time is challenging. And to go one step further, more than a few students in my seminar noted how much more they got out of the educational material because the person helping them learn it also had a mood disorder.

I should hope it goes without saying that we learn the most from those who have the most experience. A clinical psychologist can certainly teach the beginnings of clinical psychology, but a clinical psychologist who is also a professor must know the limitations of that position. They can specialize in certain disorders, but unless they have said disorders then they cannot — despite the letters after their names — teach the subject in a thorough manner. One could argue having a person with lived experience introduces bias into the educational material, but I witnessed first-hand the teaching of my diagnosis in a manner that made me, to be frank, feel quite depressed about my life outcomes. If I didn’t have the desire to learn more about the nature of my disorder, I would be left with a very bleak view of what bipolar is.

It comes down to the fact that all teachers have biases they must address before settling into education. My first “lesson” in ASTU 400L was to get people thinking about their biases before they took the role of peer-leaders in the classroom. We cannot escape bias — we can only control for it. In my case, I need to be aware of my position in the subject material. And I am, indeed, aware of my biases; for example, I love talking about self-stigma from a personal perspective. But that doesn’t blind me to accepting other points of view and discussing research from seemingly irrelevant fields. It challenges me not only academically, but personally, and I believe both obstacles have a place in the classroom. We are scholars, but we are humans. It is this shared fundamentally human aspect that is missing from the classroom and, indeed, education as a whole.

This may have concluded my BA, but this is where I begin my MEd.

Misdiagnosis in Bipolar

This post is inspired by this article which is titled “Why Bipolar Disorder is Often Misdiagnosed.” I’m going to dissect this article paragraph by paragraph. I’ll start off by saying I understand this is journalism and they need to keep it brief, but I believe people should know more than just snippets of a conversation.

About four percent of people in the United States are diagnosed with bipolar disorder at some point in their lives, according to the Centers for Disease Control and Prevention. In recent years, however, some researchers have called some of those diagnoses into question, while others have maintained that the number of people with bipolar disorder is actually greater.

Four percent seems to me like an estimate of an estimate. Research has shown varying rates from .5-5% of the population having bipolar. This is due to the samples that researchers rely on, which vary depending on a lot of factors — factors like what kind of community was sampled and what that community’s quality of healthcare, access to healthcare, and demographic features. There are statistical methods that are supposed to control for these errors, but research isn’t near perfection at this moment in time. It’s also good to note that this article outlines that the sample was taken from people who are from higher-income groups (they have health insurance), as inferred by the “pay for service” healthcare access in contrast to using “assisted payment service” (people who don’t have health insurance). Big sample differences there.

In 2008, the Journal of Clinical Psychiatry published a study that suggested bipolar disorder is often diagnosed in people who don’t actually have the condition. The researchers determined that fewer than half the people in the study who said they had been diagnosed with bipolar disorder met the clinical criteria for the illness, which causes severe swings in energy levels and mood.

The abstract really doesn’t tell you much. No one should conclude anything by reading abstracts, as they are tailored to look good and give you what the researchers believe to be the most important pieces of information. So I read the article in full, and my first problem is the way they diagnose bipolar: “Family history was used as an index of diagnostic validity” (Zimmerman, 2008). Until we figure out exactly the relationship between bipolar and genetics, indicating that family history, I question why that should be used as an “index of diagnostic validity.” Despite family history, a patient seeking help for mood problems should be seen in isolation. People without family histories can have bipolar. Though there are many studies to validate a correlation between family history and bipolar diagnosis, it’s just a correlation — not a conclusion. Further, this study uses the DSM-IV as a guideline, and we have since moved to the DSM-V. As far as I’m concerned, this is outdated and shouldn’t be used in a news article written in 2015. Science moves fast — the media should have the sense to integrate this perspective.

Mark Zimmerman, MD, the lead researcher on that study and a professor of psychiatry and human behavior at Brown University in Providence, Rhode Island, says the study also revealed that some people who met the criteria for bipolar disorder had never been diagnosed with it. But far more people had been given the bipolar label by mistake, he says. Dr. Zimmerman believes part of the reason for this overdiagnosis trend is aggressive marketing to doctors by companies that produce the drugs used to treat bipolar disorder.

This is one person’s perspective. Here we have an entire article that people will take at face value that discusses one journal article and one researcher among the countless others studying these topics. Is bipolar underdiagnosed, overdiagnosed, or appropriately diagnosed? It depends who you talk to. It depends what paper you read. Judging by this research article, I’m concluding the sample is too skewed (mostly white women) and the methodology is flawed (the questionnaires were changed during the study, so not everyone received the same questionnaire). The study also used mostly non-clinicians (as in they were either PhD students or lower on the academic food chain); one might argue this is statistically sound, but no matter what it lacks ecological validity.

“When a pharmaceutical company repeatedly says, ‘Don’t miss bipolar disorder, don’t miss bipolar disorder, and when you diagnose it, here are some medications you can use to treat it,’ there’s a tendency to expand the concept,” Zimmerman says. He says he’s replicated the 2008 findings of overdiagnosis in a more recent study that has not yet been published.

One could argue that overdiagnosis/underdiagnosis is due to the pharmaceutical marketing problem, but that seems like a personal view rather than a research conclusion. Beware personal bias, for it is aplenty. It might also be relevant only for Americans, as that’s where the problem seems to be rampant. At any rate, I look forward to reading this unpublished study and I will update this post accordingly when that time comes.

In addition, Zimmerman says, bipolar disorder shares some symptoms with borderline personality disorder, a condition marked by impulsive behavior and problems relating to other people — and because of this, people who have borderline personality disorder are often misdiagnosed as bipolar. Indeed, a review published in The Scientific World Journal in 2013 pointed to borderline personality disorder as a factor in the overdiagnosis of bipolar disorder.

The two do share symptoms; this much is true. There’s two school of thoughts that are extremes: One says that no one has bipolar and everyone has borderline, and the other says no one has borderline and everyone has bipolar. These are theoretical in the way that they are opinions held by some, and the answer probably lies somewhere in between. But again, one study suggesting that borderline is a factor for overdiagnosis in bipolar should not convince anyone about anything. The only thing it should prompt is further questioning on this topic. This article is showing only one facet of the whole story.

People misdiagnosed with bipolar disorder may experience health setbacks as a result of the drugs used to treat it. Medications including atypical antipsychotics can increase the risk for high cholesterol and diabetes, Zimmerman says. Some have also been linked to thyroid and kidney problems, he adds.

These are setbacks for people who are diagnosed properly with bipolar. Quetiapine is often cited as that aforementioned atypical antipsychotic because it works well for a variety of conditions, and works as an antidepressant at the higher dosages for bipolar depression. The thyroid and kidney problems are the lithium problems, but they don’t show up for a while and I’d be shocked if you lasted to that point without receiving or continuing on with the correct diagnosis. Lithium can also be used to treat borderline. The thing about pharmaceuticals is they tend to work differently for people, so it’s an experiment when you walk in the clinic. Maybe quetiapine is the solution to someone’s unipolar depression. There could be a few people out there like that. I’m beginning to see this more of a “be a good psychiatrist” issue than knowing how to properly diagnose a disease issue.

Up to 20 percent of people with bipolar disorder may be mistakenly diagnosed with depression by their primary care doctors, according to a study published in the British Journal of Psychiatry in 2011. A study published in Acta Psychiatrica Scandinavica in February 2013 found a gap of almost 10 years, on average, between the participants’ first onset of bipolar symptoms and their first treatment with a mood-stabilizing medication

These findings aren’t surprising, says Jeremy Schwartz, a psychotherapist in Brooklyn, New York. Bipolar disorder can be hard to diagnose, he says, because people often seek professional help only during their down periods and neglect to mention their up, or manic, periods.

Yes, that’s pretty much true, but I still dislike that ONE study is cited. Put on your thinking caps before you take that for granted. I mean, you’re cross-checking what I’m saying, right? Because you should be.

“The manic side of bipolar disorder isn’t always bothersome to people,” Schwartz says. “They have more energy, more motivation to do things. So the mental health professional doesn’t always hear about it.”

As a consequence, Schwartz says, those with bipolar disorder are often misdiagnosed with depression and may be given inappropriate treatment.

“When bipolar disorder is missed, people can be put on medications that actually worsen the manic symptoms,” Schwartz says. “So people end up waiting much longer to get the stability in their life that they’re looking for.”

Please see above comment.

The debate over diagnosing bipolar disorder may seem like an argument best left to the medical community, but people who are wondering whether they have the condition can take steps to increase their chances of receiving an accurate diagnosis. When seeking help, it’s important to talk with your doctor about all of your emotions, Schwartz says, the good ones and the bad ones. “It helps to create a fuller picture of your experience,” he explains.

This debate is at least something that should be more transparent and multidimensional in scope.

If you receive a diagnosis of bipolar disorder that you aren’t sure about, Zimmerman says, feel free to ask your doctor about his or her reasoning.

“Ask the doctor why they have made the diagnosis,” Zimmerman says. “A good doctor should be willing to discuss the reasons and to explain if they’re uncertain about it.” If you don’t receive satisfactory answers, he adds, an opinion from another doctor may be in order.

This is probably the only thing in this article I can agree with completely. Know your rights as a patient and don’t be afraid to ask for help and ask for what you need to feel secure and safe.

Elaborating on “What is bipolar?”

Defining bipolar disorder is not easy, but my previous post should give readers unfamiliar with the subject material a starting point. It’s even more difficult when the array of experiences of those living with bipolar are so diverse that every story you hear will have unique facets; albeit, there will be many common factors among we who have the bipolar brain cootie, but we’re all given the same label for more than a few reasons. However, it’s imperative to recognize and appreciate the individuality beyond the diagnosis. Henceforth I can only give examples that relate to me and my life, but there are so many more views out there that deserve recognition as well.

Bipolar began as a curse, and a large part of me still sees it as that. I’m slowly learning the positives that this illness has to offer, but I’m still not sure whether it’s confounded with personality in general. What is the disease and what is “me”? It’s a question largely unanswered by the scientific literature, but it’s pertinent nonetheless. For now I can only assume it is part of the stuff that is me. At the very least, it prompted me to start an organization dedicated to it in hopes that others out there questioning their existences can join me in the quest to further understand what bipolar is. Scientifically speaking, there’s so much more to learn.

What mania, depression, and euthymia (aka “normal”) all mean will be different for each person. For me, I’ve had very long manias (months, in a couple instances) where I had delusions, extreme motivation and ambition, and an unmatched euphoria. I’ve had depressions last but a week with brutal suicidal ideation and self-harm. That’s only the beginning of the story. When euthymic, I’ve had a pattern of being so stressed out that I make myself sick, but I’m also a successful student and artist. To get to know one’s bipolar, one must get to know oneself. There’s a conflict among many who have bipolar that asks this question: What is the disease, and what is the person? No matter where you stand in the argument, be it on either side or somewhere in the middle, you have to start asking those questions of yourself.

Of course, we can’t leave stigma out of this conversation, as it defines a lot of everyday decisions, even though it shouldn’t. Stigma exists on interpersonal, community, societal, and institutional levels. We can lose friends and family over having this illness. Our community may disown us. Society has stereotypes about us. Work can fire us for it. School can refuse to aid our needs. The health care system can still treat us as “crazy”. Those are the worst case scenarios. But we all have friends and family who love us, despite the disease. Communities have stepped up in support when tragedies, such as suicides, occur. Work can tell you that they’ll be there when you feel better. School can set up academic accommodations. The health care system prescribes medications that work and encourage healthy lifestyles to support you.

There is a range of potential challenges that comes with the bipolar gift basket upon receiving the diagnosis. I thought I was alone when that psychiatrist told me I had bipolar. But I quickly found a support group, and from there I reached out to people for support. These are the kinds of personal stories that I often find missing when I read about bipolar in this journal or that journal. Yet, they seem to help bring people together and let them know they’re not alone. So I suppose this is less of an elaboration on what bipolar is and more of an elaboration on the situation that is bipolar. And I suppose that’s what we’ll end up be talking about. How do we get someone first struggling with depression and/or mania/hypomania into the health care system without harm and see them out safely? How can we continue that support from all the levels I mentioned? This is, at the very least, food for thought.

What is bipolar disorder? 2015 Edition

I had no idea what bipolar disorder was until after I had been diagnosed with it, so I’m assuming that the percentage of the population that doesn’t fall into the 1-5% of the population diagnosed with the disorder may have a pretty vague idea as well. Even those with bipolar disorder might be unclear about their experiences. I know I was until I started researching it. I still am, to some degree.

Bipolar disorder is defined in two separate and major publications – the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), and the International Classification of Diseases, tenth edition (ICD-10). The former is what I will be basing this discussion on, seeing as it is the main text used in clinical practice in Canada (where I reside) and the USA. It’s interesting to note that the DSM-V and ICD-10 differ in their diagnostic criteria, but I will save that for a future post.

According to the DSM-V, the following types of bipolar disorder currently exist: bipolar disorder type I, bipolar disorder type II, cyclothymic disorder, substance/medication-induced bipolar and related disorder, bipolar and related disorder due to another medical condition, other specified bipolar and related disorder, and unspecified bipolar and related disorder. The first three are the diagnoses that get the most attention in research, from what I’ve read and seen. This may or may not have something to do with the “illness burden”, or how difficult these illnesses are for people to endure.

Bipolar Disorder Type I
Type I is by far the most heavily researched and thus we know the most about it. The DSM-V requires the occurrence of mania alone to diagnose type I; hypomania and a major depressive episode are common in type I, but not necessary.

Bipolar Disorder Type II
Type II is less studied than type I, but more and more is being seen as a distinct diagnostic entity – it used to be considered a less severe form of type I in the DSM-IV, though I still see that sentiment in some psychiatrists I have spoken with. In order to be diagnosed with type II, the presence of a hypomanic and major depressive episode are both needed.

Mania, Hypomania, and the Ladder of Neurological Excitability
…the topic that appears to be the most interesting when it comes to bipolar disorder, but what is it? Before I summarize the DSM-V criteria, I want to stress that individual difference is the special ingredient here. When it comes to mania/hypomania, every person has a unique story (or stories – usually stories) to tell. We who have been cursed/blessed (depending on your experience) with riding the waves of neurological excitability experience those waves in particular ways. Some ride them out like surfing stars, others drown and sink to the ocean floor, and still others find themselves wobbling on their boards not sure what to make of it. And still others have a completely different metaphor than I do for mania and that’s valid and true too. Here’s what the DSM says we experience when manic/hypomanic:
1. Elevated mood, grandiose thoughts/feelings
2. Little to no need for sleep
3. Desire to be more talkative or internal pressure to be that way
4. Racing thoughts
5. Easily distractible
6. The pursuing of goals with fervour, whether purposeful or not
7. Involvement in activities seen as reckless that one would otherwise not do

A manic episode is defined as a week or more with three or more of these symptoms, and hypomania is just four days or more with three or more of these symptoms. They both need to be independent of any other underlying condition and/or substance use. Mania also has the caveat of psychotic symptoms and can require hospitalization because of the lack of proper functioning a person usually experiences during mania. Hypomania, however, is usually seen as increased productivity/socialization/lifeness that doesn’t usually interrupt typical functioning in day to day life (but is still not the best way to function with your health in mind).

Personally, I find the descriptions of symptoms to be far too simple to describe what I experience during mania and hypomania. There are too many intricacies and it really just doesn’t do my experiences justice. I’ve heard similar sentiments from others with bipolar disorder.

Depression and the Black Dog that is More Like a Sea Monster
Depression is the other side of the bipolar spectrum. A major depressive episode includes five or more of the following symptoms for a two week period or more:
1. Depressed mood (thank you Dr. Obvious)
2. Lack of pleasure/interest in life in general
3. Significant weight loss/gain and increase/decrease in food intake
4. More/less sleep than normal
5. Feeling restless or slow
6. Feeling tired almost every day
7. Feeling worthless
8. Cognitive impairment recognized by self and/or others
9. Suicidal ideation, with or without tangible thoughts of a plan

Again, these symptoms need to be independent of any underlying medical condition and substance use and must cause clinical distress (still trying to find the person who doesn’t find depression stressful – thanks again Dr. Obvious). Depression is a tricky beast because there’s a line that one eventually crosses from “psychologically distressed” to “clinically depressed”, and gauging that line can be difficult internally and externally. I didn’t really have an idea of how depressed I could get until someone witnessed me at my worst, and yet some people would never guess that I struggle with depression. I have – like many others – mastered the art of faking a smile.

Would You Like Rapid Cycling with Your Order Today?
So there are these awful fun add-ons that you can have with your bipolar disorder, just in case cycling between feeling amazing/irritated/angry and depressed wasn’t enough. These two are the most common that I read about:
-Rapid Cycling: DSM-V describes this as having four or more episodes in a twelve month period.
-Seasonal Pattern: Essentially, Seasonal Affective Disorder (SAD) – for me, it’s mania/hypomania in the spring/summer and depression in the fall/winter (though there are exceptions). Thanks, brain.
The DSM-V also lists the following: “anxious distress, mixed features, melancholic features, atypical features, mood congruent/incongruent psychotic features, catatonia, and peripartum onset”. I haven’t encountered these things as much, and the DSM-V doesn’t go into them much so I have no wisdom to spread upon this issue.

Mixed Episode: The “I’m So Happy I Could Kill Myself” Meme
A peruse through google images makes that meme pop up a lot. A mixed episode is pretty much what it sounds like – a mix between manic and depressed features. It feels like you’re really losing your mind because nothing makes sense. It’s an insane concoction of mania and depression and it’s worse than depression, in my opinion. It’s not well understood, however. More on this one in a later post.

Comorbidity: A Gift with Purchase
There are a few disorders that tend to coincide with bipolar disorder. From what I’ve learned, anxiety disorders, obsessive compulsive disorders, and AD/HD tend to be the main culprits, as well as eating disorders. Bipolar disorder on its own is difficult to treat, never mind adding in some irrational fears about failing at life and needing everything to be symmetrical, for example. According to the DSM-V, bipolar disorder and some personality disorders tend to overlap as well, namely borderline personality disorder. Again, that’s an interesting topic that needs further debate.

So there’s a basic clinical guideline to what bipolar disorder is. Again, I want to emphasize the importance of NOT generalizing experiences from person to person just because they all have the same diagnosis. During mania, some people have crazy spending sprees, some engage in risky sexual acts, some find gods and get to know them too well, and still others just talk a lot about this really amazing idea that will save the world that you should believe because that’s all you need in life. It really just depends on the person. I firmly believe that thinking about bipolar disorder in this way will encourage more accurate research and treatment, as well as help the stigma and self-stigma associated with the disease. And on that note…

Yes, Bipolar Disorder is A Medical Condition and Here’s Why
There is a metaphorical giant pile of research papers (because we’d kill a lot of trees to print it all out) that exists explaining the neurological, genetic, and otherwise biological basis of bipolar disorder. To say it’s complicated would be an understatement, and summarizing the research isn’t really possible. However, a simple Google Scholar search of “bipolar disorder” and “biology” or “neurology” will clarify the issue and should erase doubt completely. Also, people who take medication for the disorder (like me) have been able to live productive, functional lives that they didn’t have before they started treatment.

A lot of people say depression is selfish and/or otherwise in a person’s head and they can just “stop being depressed”. That’s an entirely different conversation and I have quite a lot to say to those sentiments. For the time being, I will simply put forth this thought: Why criticize someone who feels sad? I just can’t fathom why people – be it clinical depression or simply sadness – would approach such a person with hatred rather than compassion. Likewise, calling someone “crazy” doesn’t help anyone, so why waste your time?

I hope this begins an educated discussion about the intricacies of bipolar disorder. This is an edited version of the post I first made on my other blog. Hello new blog!