S1:E1 Bipolar Uncovered
Bipolar Support Resources
Bipolar Subreddits
Transcript
ANNA: Welcome to Courage to Heal – a podcast where we explore the battles we wage within ourselves. I am your host, Anna Khandrueva, a psychotherapist and a mental health advocate. This is Episode One: Bipolar Uncovered.
Hello, everyone, and welcome to our very first episode. Today, I want to talk about bipolar disorder. We will be doing a deep dive into this condition during our first season through several interviews with people who live with it. Why bipolar? Well, this topic is near and dear to my heart. Not only do I work with it as a mental health professional, I also live with bipolar myself. I hope to give you an overview of this complex illness as well as share my personal story. Let’s begin.
There are about 46 million people around the world living with bipolar, but that only includes diagnosed cases. I have every reason to believe that many more people are out there undiagnosed or misdiagnosed. In the US, a little over 4% of adults are classified as bipolar at some point in their lifetime. By comparison, in India that number is only .3%. I don’t think that there is anything inherently different about Americans that makes them have a higher rate of bipolar. I believe the difference is due to the number of people who seek diagnosis and treatment in the first place. Many don’t do so due to cultural stigma.
It’s important to know that bipolar runs in families – 2/3 of people with bipolar have a close relative who also has the condition. As a matter of fact, bipolar is one of the most heritable mental health conditions. If one parent has bipolar disorder, there’s a 10% chance that their child will develop the illness. If both parents have bipolar disorder, the likelihood of their child developing bipolar rises to 40%.
Bipolar can be diagnosed at any age, but on average, symptoms start at the age of 25. They can also show up much earlier, especially in people who experienced childhood trauma. The 18 to 34 age group is the most likely to receive this diagnosis.
No one knows what causes this illness. Patients have different brains on MRI scans, but we don’t know what causes the differences. Bipolar disorder, just like the name implies, has a dual nature. On one side, there is depression, a state of low energy, low mood, and low motivation. On the other side, there is mania or hypomania, a state of incredible energy, elevated mood, and often enough, irritability. In depression, you feel worthless. In mania, you feel invincible. These two states live within you, sometimes dormant, sometimes alive, but never completely gone. There is no cure for bipolar. Once you are diagnosed with it, you have it for life.
Despite this dramatic declaration, it is possible to live a good life with bipolar. I am living proof of that. Once I got properly diagnosed and medicated, life became not only bearable but good. But let me go back to the beginning.
Before becoming a psychotherapist, I worked in the mortgage and finance industry. I can’t say I enjoyed it all that much, but it was a fine way to make a living. Except something was wrong. I would get so sad and numb for so long that all I could do was sit home and drink wine. I no longer wanted to live despite having an objectively good life. I finally recognized there was an issue and went to see a psychiatrist. “Major depressive disorder,” he said without lifting his eyes off his desk. He prescribed Prozac. Taking Prozac was the worst experience of my life. I became irritable, agitated and was completely unable to sleep. I didn’t know what was happening to me, and I was miserable.
This is not an uncommon start to one’s bipolar journey. Bipolar is often misdiagnosed as depression. After all, most people with bipolar only go to seek help when they feel at their lowest. Up to 40% of people with bipolar initially receive the major depressive disorder diagnosis. It takes going through about 4 healthcare professionals before that person is properly diagnosed. And antidepressants, when taken without mood stabilizers, can trigger manic and mixed episodes. The latter is a paradoxical state where mania and depression come together and punish you with unbearable emotions and sensations.
I tried several antidepressants without much success. The depression always came back. I had to go on 2 medical leaves because of it. Here’s the weird part. When not on leave, I would try to start my own business but never in a planned out, dedicated way. I would find a new thing, invest a bunch of time and money into it, then abandon it two weeks later. I tried to write a book. I wanted to make my own app. I wanted to start a body language company.
The money alone was a big issue. I spent thousands of dollars and went into debt because of these silly ideas. My husband was shocked when he found out the extent of it. I was convinced I could pay it all off as soon as my ideas took off the ground. I thought I was just uncommitted and incompetent. “Not enough motivation and hard work,” I would tell myself, “The next thing will be it for sure.” These periods of high productivity were permeated with depression. Every time it happened, I thought “finally, I’m out of the darkness!” But the good times never lasted. Inevitably, I would sink back into the depth of despair.
Finally, I switched psychiatrists because of a change in my insurance. The new doctor, quiet and pensive, took his time asking me questions – not just about depression, but about those silly times in between. After much deliberation, he said the magic words: “I think you have bipolar disorder.” I have heard the term before but knew very little about it. I was 33 years old. Little did I know, my life was about to change forever.
People understand depression. They have a general sense that it is a deeply miserable place to be. Depressed people can lose interest in all activities they previously enjoyed, they can lose their appetite or overeat, they are usually fatigued and lethargic, sleeping way too much and doing way too little. They start feeling like life is not worth living and sometimes attempt suicide. I could wrap my head around this concept. But those times in between, where I experienced myself to be the smartest, the brightest, the best… those times were not as clear. Now I know that those are called manic or hypomanic episodes.
The symptoms of mania and hypomania are the same, the difference lies in severity. Mania is more pronounced and severe – other people are likely to notice if you are manic because your behavior can be so outside of the usual range. People with mania can experience psychotic symptoms, like delusions and hallucinations, and they can even be hospitalized because of it. With hypomania, things are not so obvious. People in a hypomanic state can seem really productive, creative, and put-together to others.
Let’s go through what people with mania and hypomania experience. The main symptom they have is highly elevated or irritable mood. They are also really distractible and impulsive, often engaging in risky and reckless behaviors. Things like gambling and excessive shopping are common. They have a drastically decreased need for sleep, unable to rest for more than 2 to 4 hours a night but still having plenty of energy. Their heads are filled with endless ideas that rush around with no end in sight. They are preoccupied with tons of activities and projects, one more grandiose than the other. Remember all those ideas I had about writing books and starting businesses? Yes, that’s it. Two other common symptoms are fast speech and hypersexuality.
Hypersexuality is worth talking about more. It sounds more glamorous than it is. It feels like a compulsive pressure for sexual gratification regardless of consequences. People in this state can engage in things like non-consensual voyeurism, unprotected sex, or sex with people they wouldn't otherwise be attracted to. They can also engage in excessive masturbation to the detriment of their life obligations. In other words, sexual desire completely takes over their life. This can hurt both the person and their relationships. Unwanted pregnancies, STIs, cheating, and legal troubles can all be consequences of hypersexuality.
So, that’s mania and hypomania for you. I’m not going to lie; hypomania can feel good. You can feel on top of the world, your senses are sharpened, your brain is at its brightest. You are firing on all cylinders and life seems full of color. You can taste the sun and the sky, and anything seems possible. But the compulsive spending and sexual behaviors certainly make it less fun. Plus, remember when I said that your mood can be either elevated or irritable? Bipolar irritability and anger are nothing to joke about. They can be overwhelming taking over all reasonable parts of you.
Bipolar is not all one flavor. It comes in 3 different types. First, there is bipolar type 1. To be diagnosed with that, all you need is a manic episode. Mind you, this doesn’t mean that people with type 1 don’t experience depression. The disorder overall is mostly depressive, with 75% of episodes being depressive rather than manic or hypomanic. For type 2, you need to have both periods of hypomania and depression, but never mania. Women are more likely to have bipolar type 2, and they typically have longer depressive episodes. In general, depression in type 2 is more chronic, sometimes lasting for months and even years. And the third type is called cyclothymia, where episodes of mild depression and hypomania persist for at least 2 years with no more than 2 months in between these episodes. There is also unspecified bipolar, which is a catch-all term for anything that doesn’t quite fit into the above buckets but is under the bipolar umbrella.
I often get questions about how many episodes people go through in their lifetime. The answer varies a lot. In one study, people reported an average of 20 lifetime episodes, but these people were around 40 years old. Logically, you would conclude that the number is higher than 20 for one’s entire lifetime. Then, there is an issue of rapid cycling. Cycling in general refers to how often a person goes through episodes. Like I mentioned, for some people depressive episodes can take months or years. Hypomanic and manic episodes are usually much shorter, rarely lasting more than a few weeks. Some people, however, rapid cycle. This means they can have 4 or more episodes in one year. Then, there is ultra-rapid cycling, with only days or a couple of weeks in between episodes. Some research even alludes to ultra-ultra-rapid or ultradian cycling, meaning the episodes can have as little as a few hours in between them.
Another thing about this disorder, is that it’s really common to have other mental and physical health conditions if you already have bipolar. Bipolar and anxiety go hand in hand – half of people with bipolar also have some kind of an anxiety disorder, with panic disorder being the most common. I, myself, have generalized anxiety disorder, which means that I am generally anxious most of the time for no reason. At least 17% of people with bipolar also have ADHD, and kids who are diagnosed with ADHD are 10 times more likely to develop bipolar later in life. Once again, I’m the lucky winner of this lottery. People with epilepsy are almost 7 times more likely to have bipolar than healthy people. As many as 29% of people living with bipolar disorder have experienced migraine. That's a significant difference compared to 12% of the general population who have migraine. And when it comes to substance use disorders, the rates are staggering. At least 40% of people with bipolar 1 also have a substance use disorder, with alcohol and cannabis abuse being the most common, followed by cocaine and opioids.
Once I learned all of this about bipolar, everything started falling into place. My behaviors finally had an explanation. My actions, no matter how irrational, made sense within the frame of this illness. I realized that my bipolar symptoms started when I was a teenager, when I would go through manic episodes believing I had special powers and could talk to trees and the wind. I realized that the deep depression I went though in college was just one side of the coin, surrounded by those short bursts of activity and creativity when it seemed like I could do absolutely anything I set my mind to. The anxiety, the alcohol abuse, the frustrating lack of executive functioning… I now understood myself better than I ever have before. I have bipolar type 1 and I will have it until the day I die.
It took me another 2 years from diagnosis to find the right medication. Bipolar is notoriously hard to treat. You can’t just address mania or depression – you have to get both under control in a delicate balance. Those who are medicated take 3 medications per day on average – and may take others to manage the side effects. Sometimes, the meds that have worked great stop working, and we don’t know why. Other times, the people living with bipolar stop taking the meds once they feel better, thinking they are cured. This is actually a big problem with this illness. People who become stable start to doubt they are sick at all. I can relate to that. I have been relatively stable for the past 4 years – the years during which I was able to go to graduate school and a post-graduate program and to start my own business of being a therapist. I still get periods of mild depression and hypomania, but they are manageable with lifestyle adjustments. While this sounds good, I live in constant fear of losing my insurance. In the US, my medication would cost me over $1,500 a month if insurance didn’t cover it. If I lose that, I could lose everything.
This is a problem for many people since good insurance usually comes with a good job. People with bipolar have a really hard time finding and keeping jobs – about 60% are unemployed, and out of those who are employed, 90% make less than $30,000 a year. This disorder has one of the highest rates of impairment, with many people struggling on disability. Globally, it’s the 6th leading cause of disability. And since we are on a depressing topic already, let’s keep going. I’d like to issue a trigger warning for people who may not want to hear about the worst of it.
1 in every 5 people with bipolar dies by suicide. Many more attempt it. They self-harm at much higher rates than people with regular depression. On average, their lives are 8-12 years shorter due to various health conditions like cardiovascular disease and epilepsy, that seem to affect people with bipolar to a higher degree. I don’t think I need to say more on this. I don’t think I want to. After all, this is not just their reality. It’s mine, too.
There are all kinds of special considerations with this illness. For women, going through pregnancy and childbirth can cause all kinds of instability, with post-partum depression being quite common. But very few people know about post-partum bipolar, where symptoms can begin seemingly overnight after delivering the baby. This includes medical professionals. Mothers are not screened for it even if they have a history of bipolar in their family. And women who already have bipolar before they become pregnant face a difficult choice: keep taking medications during pregnancy and fear harming your unborn child or stop taking them and fear harming yourself. Personally, I had my son before being diagnosed, and I went through a long period of deep, dark postpartum depression. I have very foggy recollections of the first few months of my son’s life, and I will never get that time back, the time I could be bonding with him and making memories for years to come.
Another thing to consider is the presence of trauma. People with bipolar are twice as likely to have multiple traumas in their lives, starting in childhood. Around 60% of people with bipolar experienced verbal or emotional abuse as children. Emotional abuse has the biggest impact by far, followed by emotional neglect. People who were abused as children have higher severity of all symptoms from depression to anxiety to impulsivity. They have more depressive and mixed episodes, experience more suicidality, have an earlier onset, and are more likely to cycle rapidly. Even adulthood stress has negative consequences: people with bipolar who experience traumatic and stressful situations as adults take 3 times as long to recover from episodes as people without adversity.
This is all a bit gloomy, isn’t it? Let’s talk a bit about more positive things, like what you can do to live a better, more stable life with bipolar. I already mentioned medication as a major helper. The reality for a lot of people with bipolar is they will need to take some form of medication regardless of their symptoms subsiding. We cannot just stop taking our meds when we feel better – that’s a trap. But once the proper medication balance is achieved, life can be pretty good, and I am living proof of that. Not only am I able to help myself, I am also helping others through my profession. It’s possible to tame this beast.
There are many other strategies for managing bipolar – not everyone chooses or has to take those meds. Maintaining a stable sleeping and eating schedule, exercising, taking supplements, avoiding substances, and attending bipolar-specific therapy can go a very long way. Some recent research suggests that certain types of diets, like keto, can reduce bipolar symptoms, although this needs more investigating. Things like light and dark therapy – using a mood light for depression and a dark room or amber glasses for mania are accessible to people on modest budgets. And there are activities to fight cognitive decline that’s common in bipolar, like reading, puzzles, writing and performing music or poetry, learning new skills, dancing, playing board games, and even simple socializing.
It can be really helpful to have an ally – a friend or a family member who takes their time to learn about bipolar symptoms and warning signs and who can tell you when they start noticing those warning signs in you. For example, being way more cheerful than usual and talking in a fast, pressurized manner can be dead giveaways. This ally not only helps you see when an episode is starting, they can also help you get through it in a less damaging way. Social support is a huge factor in how well a person navigates bipolar according to research.
As a therapist, I have to give a shoutout to some specific therapies that can be helpful. IPSRT, or Interpersonal and Social Rhythm Therapy was designed specifically for bipolar. It’s not your typical talk therapy - it involves identifying your lifetime triggers, learning the warning signs, understanding your circadian and social rhythms, and keeping a stable schedule. Another bipolar-specific therapy is Family Focused therapy. It involves the whole family learning more about the disorder and how to help their loved one with bipolar function their best. It encourages things like regular family meetings and having a plan for emergencies to improve the person’s overall chances of staying stable and safe. The last resource I will mention is support groups. There are plenty of in-person and virtual support groups where people can hear stories of pain and success, stories that help them relate and not feel so alone. My favorite resource for support groups is the Depression and Bipolar Support Alliance, which you can find at dbsa.org.
To sum up, bipolar is a very complex and serious condition. It’s a lot more than simple mood swings, and it’s hard to recognize and treat properly. But there is hope. There is always hope. People do get better. They get better when they learn more about the condition and get help from professionals, from friends, from family, and from themselves. It takes courage to heal, and courage is what people with bipolar have in spades. There are vibrant communities online where support can be found. You can find them on Reddit, Instagram, Facebook, and online forums, and I will include them in the podcast notes. Knowing you are not alone is half the battle. I hope that my story does just that – let people know they are not alone in their suffering and recovery.
I want to thank you all for listening today. Your support means the world as I hope to spread awareness about bipolar and many other mental health conditions through this podcast. Please subscribe and leave a review to help other people find Courage to Heal.
For our next episode, stay tuned for an interview with my husband who will share his view of my bipolar struggles. Until then, take care and stay courageous.
