The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) devotes a full section to bipolar disorders. It describes them as distinct illnesses—things you do or do not have. Experts know this is an oversimplification. Like nearly all mental health conditions, “bipolar" is a spectrum.
Within the spectrum are successful, well-adjusted people whom no one would describe as having a “disorder” and people so severely impaired that they can never lead normal lives.
Bipolar refers to opposite extremes or poles. In its most severe form, a person cycles between the oposite poles of depression and mania (“bipolar I disorder,” according to the diagnostic manual). Mania is a state of excessive energy and excitement, of being abnormally “revved up.” Someone in a manic state may have racing thoughts, talk too fast, have little need for sleep, or believe they can do or accomplish anything.
One manic patient thought he could remodel his whole house overnight (he destroyed his home with a crowbar and sledgehammer before being hospitalized the next day). Another believed he could write a novel overnight and produced hundreds of pages of gibberish. Others go on reckless spending sprees or squander their life’s savings on ill-conceived business ventures.
But those are textbook cases of mania. The bipolar spectrum includes people who never experience full-blown mania. They may instead experience hypomania. They are revved up, but not to the point of doing things that are abnormal. They may think faster, have more energy, require less sleep, and often do and accomplish more than other people. They may be dazzlingly brilliant, especially in artistic and creative fields. It is as if their brains are turbocharged.
(A disproportionate number of extraordinarily accomplished people—from Napoleon to Beethoven to Ernest Hemingway to Winston Churchill—are thought to have suffered from bipolar disorders).
Some people have intermittent hypomanic episodes. Some seem to function in this turbocharged way most of the time; it is their “normal.”
Kay Redfield Jamison, a professor of psychiatry who has written movingly about her own bipolar illness, described hypomania this way: “When you’re high, it’s tremendous. The ideas and feelings are fast and frequent, like shooting stars… Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty.”
This energy and creativity comes with a terrible price. Sooner or later, hypomania gives way to depression (“bipolar II disorder,” according to the diagnostic manual). A few blessed souls seem to get mainly the benefits of the bipolar genes: They get the turbocharged brain and boundless energy but seem to escape debilitating depression. They are the rare exceptions.
Bipolar disorders give rise to other mental health problems, especially alcohol and drug abuse. The connection is straightforward. During hypomanic and manic episodes, people behave recklessly and feel invincible. There is no internal brake. When they descend into depression, they may try to self-medicate with alcohol or other drugs. This inevitably makes things worse.
Professionals who see large numbers of patients develop a “feel” for different mental health conditions. They develop an eye and ear for how they look and sound. I would never diagnosis a patient based on just an impression, but the truth is, I often have a good idea what is wrong when a new patient first enters my office. So do other experienced professionals. Many mental health conditions, including bipolar disorders, have distinctive “signatures.”
Robin Williams was never my patient. I know nothing of his life beyond what I’ve seen in the media. I offer opinion, not fact. But I have never watched Robin Williams without thinking “hypomania.” It did not seem subtle. I hoped he was one of the lucky few who got the turbocharged brain and boundless energy without the crippling depression. But I knew the odds were against it.
Bipolar disorders are treatable. But they often go undiagnosed and untreated, or improperly treated. Bipolar depression requires different treatment than other forms of depression. It is a different animal.
Health care professionals are less familiar with bipolar depression than other forms of depression. Your doctor can likely diagnose depression but may not be able to connect the dots to recognize bipolar disorder. Also, people with bipolar disorders tend to seek help when depressed, not manic or hypomanic, so even mental health professionals can miss the big picture. One study found it took an average of nine years for a person with bipolar disorder to be diagnosed correctly.
Good care means a sustained relationship and ongoing, regular meetings with a psychiatrist expert in treating bipolar disorder (here is an excellent New York Times Op-Ed piece abut this). An ongoing treatment relationship allows the psychiatrist to track the person’s mood and see both the ups and the downs. Crises can be averted before they become crises, and when a crisis does occur, there is a relationship with a trusted professional to turn to.
Few Americans get this kind of care. Health insurers balk at paying for regular, ongoing treatment. Unless a patient is in crisis, they do not consider it a “medical necessity.” But by the time someone is in crisis, it may be too late.
I do not know whether or not Robin Williams had an ongoing treatment relationship or if his suicide could have been prevented. I do know that good mental health care prevents tragedies.
Jonathan Shedler, PhD practices psychotherapy in Denver, CO and online by videoconference. He is a Clinical Associate Professor at the University of Colorado School of Medicine. Dr. Shedler lectures to professional audiences nationally and internationally and provides online clinical consultation and supervision to mental health professionals worldwide.
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