Are You Bipolar?
Mild bipolar disorder may be to this decade what depression was to the nineties, thanks to a new drug and an expanding definition. But when do ordinary peaks and valleys become pathological?
By Vanessa Grigoriadis
(Photo: Andrew Eccles)
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."