Is My Depression Really Bipolar?
"[My best friend] and my husband have told me I need to be checked for bipolar, but everything I've read, up until finding your site, showed I did not have all the symptoms, which is the mania - having ups. I never have those."
Thank you for writing, Ticadoo. You have raised what I would characterize as bipolar's biggest myth - namely, that to rate a diagnosis you need to be dancing on tables.
Ticadoo mentions that she has been treated for depression for a good 20 years, then continues:
"But I do have depression ... and angry outbursts. ... Is there a bipolar that is just anger and depression? Please help. I am about to lose my family."
This is a really important question, Ticadoo. I can't call your diagnosis for you, but here are some things that you and everyone else who experiences depression needs to know:
In bipolar, mania gets all the attention, but the hard cold fact is - according to studies conducted by Robert Post MD for the Stanley Foundation Bipolar Network in 2001 - we are depressed three times more than we are manic.
I was in attendance at the Fourth International Conference on Bipolar Disorder when Dr Post dropped this little bombshell, and - trust me - you could have have knocked everyone in the room over with a feather. For bipolar II, the estimates go a lot higher.
The first modern DSM - the DSM-III from 1980 - made full-blown mania a criteria for bipolar. Because that version and its revision of 1987 did not recognize bipolar II, psychiatry mistakenly lumped anyone with light manias (hypomania) into the same class of patients with unipolar depression and treated them the same, with often disastrous results.
The DSM-IV of 1994 recognized the new category of bipolar II, with its lower threshold for hypomania rather than mania, but a strong body of expert opinion posits this doesn't go far enough. We think of hypomania as something we wish someone could put in a bottle and sell. Think of being Marilyn Monroe or Bill Clinton for a few days.
But for many people, hypomania is more like road rage. We experience the surges of energy, but the outcome is anger.
And here's another important consideration: For many of us, our ups are barely noticeable. We may simply cycle up into a state of feeling slightly better, which is not exactly a red flag that something is amiss.
A twist to this is that when we are depressed, we cannot recall our good times (or for that matter our embarrassing moments). Since we tend to seek out help only when we are depressed, our psychiatrists get a very one-sided view of our condition. Typically, those with bipolar II endure 10 years of the wrong diagnosis.
This is why, Ticadoo, it is advisable to have your husband present at your psychiatric consultation. You are likely to talk about being depressed and angry. The anger should be a red flag to a clinician, but your husband probably needs to prompt you with something like: "Tell him about the time you threw your laptop out the window." I heard Frederick Goodwin MD, co-author of the definitive work on bipolar, make precisely this point (without the laptop example) to a DBSA group he addressed in Washington DC two years back.
Way back in the old days, what they used to call manic-depression also included recurrent depression, and Dr Goodwin is leading a movement to revive this view. In other words, you may cycle in and out of depressions in a pattern similar to bipolar, but without the signature highs. There is a strong body of expert opinion that believes these types of recurrent depressions should be recognized as a form of "soft bipolar," a "bipolar III," if you like.
There is a catch-all "NOS" (not otherwise specified) category that clinicians use in a pinch for would-be bipolar IIIs, but the label hardly matters. What is important is that the condition is recognized and treated accordingly. In some cases, this means going with bipolar meds (to treat the cycle) rather than antidepressants (which might exacerbate the cycle).
Finally, the catch: A lot of clinicians are unaware of bipolar II or its "softer" manifestations, much less how to treat them, so please do not hesitate to seek a second opinion.
And finally again: Bipolar II and its softer manifestations are extremely difficult to identify, even by experienced clinicians. So please don't automatically jump to the conclusion that you may have bipolar. But the fact, Ticadoo, that your antidepressant treatments haven't been working for you presents a strong case for you and your psychiatrist (with your husband in attendance) revisiting - albeit cautiously - your original diagnosis.