The Importance of Early Intervention With Bipolar Disorder
The wisdom of a young adult’s proactive request for consultation
Posted Jul 23, 2020
One of the predominant challenges in treating young adults with bipolar disorder is helping them to accept the reality of their diagnosis. It is often met with resistance as its implications are too painful to integrate into young adult identity development. This resistance, or sometimes even outright denial, often leads to delays in obtaining appropriate treatment, reluctance to incorporate healthy lifestyle changes, medication noncompliance, worsening symptoms, and most concerning, negative impact upon long-term prognosis for the course of the illness.
Occasionally I see a new patient who does not conform with the above characterization. He or she recognizes early on that something unusual is happening and appropriately decides to seek consultation. Wendy is a good example.
In her initial email to me she expressed that she was concerned she might have bipolar disorder and wanted to make an appointment for a psychodiagnostic assessment. Wendy was age 20 and a third-year university student. In our initial telehealth video session, she provided the following account of unusual mood intensity.
She had returned to her home in March to complete the academic semester remotely because of the COVID-19 pandemic. Upon returning home she said she “felt off—different than usual—not her normal self.” She reported that by mid-April she began to experience rapid cycling mood changes, which were new to her. She had previously had some episodes of depression but had not experienced any previous cycling between depressed and elevated mood phases. She also reported that she was not using any substances that might have explained or contributed to the variations in mood intensity.
When asked specifically about mood elevation she reported the following symptoms: increased energy (feeling “hyper, excited, wired”), lessened need for sleep (3 to 4 hours without daytime fatigue), racing cognition, rapid speech, elevated libido (stronger than normal for her), and difficulty maintaining cognitive focus, attention and concentration. She also described being highly gregarious, impulsive, and strongly emotionally expressive when around others. She notes that her behavior was very atypical for her. Her mood elevations lasted from one to three days and were then typically followed by depressive episodes.
With regard to her depressive symptoms, Wendy reported: low energy, low motivation, anhedonia (absence of pleasure), low self-esteem, feelings of emptiness, periods of feeling numb/disconnected from her surroundings, interpersonal withdrawal, and hypersomnia (excessive sleeping—10-14 hours). Wendy further reported that these depressive episodes would last between three to five days and she would then transition back to mid-range mood.
Wendy did not closely track her mood cycling but she thinks that over a one-month period, she cycled between elevated and depressed mood approximately three to four times. By the time she had contacted me, she was approximately one month past her last set of symptoms. She was feeling relatively stable yet apprehensive about the potential return of mood instability.
Wendy’s symptoms were classic examples of hypomania and bipolar depression, but they did not meet the duration threshold to qualify for the bipolar diagnosis. According to the DSM-5, hypomanic symptoms need to be present for four days or more while depressive symptoms need to be present for two weeks or longer.
So, considering these criteria, what was my response to the assessment question of whether Wendy had bipolar disorder?
Simple answer: It looked like her recent experience might represent the onset of bipolar symptoms, but at the time of our assessment it was too early to know with certainty. I conveyed that the answer would likely become clearer to Wendy over time, particularly if Wendy’s mood patterns persisted and/or strengthened in duration and acuity. We also could not dismiss the combined circumstantial impact of leaving school mid-semester and returning home while facing end-of-semester academic stress. It could be that Wendy’s rapid cycling was not bipolarity but a single anomalous experience, not easily explained diagnostically.
I met with Wendy several more times beyond the intake and our work contained a strong psychoeducational focus. She did understand that she could be looking at the early stages of emerging bipolarity, and while I couldn’t be more definitive about the diagnosis with her, I directed my efforts towards helping her learn about the disorder and the lifestyle choices that can help support stable mood functioning.
A psychiatric referral was also made for a second diagnostic opinion and to discuss medication options that Wendy could consider, either now or if mood symptoms were to return. To date she has not yet followed through with the psychiatry option, but she does intend to.
Essentially, my goals with Wendy were to help her learn more about bipolar disorder and to develop a clear game plan if her mood instability returns. I also did my best to convey that it could be risky for her to ignore the recent cycling and proceed without cautious vigilance.
Wouldn’t it be nice if we had more young adults as mature as Wendy? Rather than avoiding professional help due to anxiety or fear of stigma, she proactively and maturely sought help with legitimate concerns about potential bipolar symptoms. By doing so, Wendy is now better prepared to successfully manage future symptoms should they return.
Wendy is also a role model for young adults who may be experiencing early signs of mood instability. When it comes to mental health issues, people are so much better off seeking help sooner than later, before things worsen and become difficult to manage.