Bipolar Disorder
What Bipolar Disorder Actually Looks Like
Bipolar disorder, historically referred to as manic-depressive illness, is a disease which affects roughly 1-2% of the world’s population. It was first properly described as such by Emil Kraeplin in 1898, though descriptions of mania date back to ancient times.
Bipolar disorder at its core is an episodic condition that leads to periods of either depression, mania (or hypomania), and mixed states that combine features of both. We refer to these as “mood episodes.” There are commonly long periods of time between episodes, up to months or many years. Despite this, bipolar disorder is considered a lifelong condition, and mood episodes can always recur.
While the popularly understood explanation of bipolar disorder is that a person with the condition will be either depressed or manic when the disease is active, the reality is that a majority of people experiencing an episode will be in a type of mixed state. We can think of the possibilities as a type of spectrum:
Pure depression > agitated depression > depressive mixed state > dysphoric mania > pure mania
Note that this implies that not all depressions are stereotypically low energy and dominated by sadness. Nor are all manias defined by euphoria or positivity.
Another important diagnostic factor to consider is timeline. Most typically, bipolar disorder presents in early adulthood, but not uncommonly presents in adolescence or middle age as well. This may be partially due to the severity and quality of episodes: a severe manic episode early in life makes the diagnosis obvious. A few hypomanic episodes followed by depressive episodes may go unnoticed or untreated for decades.
The reality is that these episodes are almost always self-limited. Depressive episodes tend to last longer, on the order of weeks to months. Manic episodes are usually shorter, days to weeks. Depression often follows mania, but not always. People can kill themselves at any point, though the times of transition between states are particularly dangerous, especially if someone is moving from depression to mania.
In the most severe cases, the mood episodes lead to psychotic features like paranoia and hallucinations, which often resolve when the mood episode improves. This is different from a disease like schizophrenia in which the psychotic features are persistent, lifelong, and not related to a patient’s mood state.
While we are speaking of bipolar disorder generally here, the current DSM-V differentiates between bipolar I disorder, bipolar II disorder, and cyclothymia. In the next section we will explore the differences.
Bipolar I vs. Bipolar II vs. Cyclothymia
Bipolar I disorder is what you will see most commonly referred to as simply “bipolar disorder.” This diagnosis can be made if there has been at least one manic episode, which by the DSM-V is defined as:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:
- Inflated self-esteem or grandiosity
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless, non-goal-directed activity)
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
Therefore, if you have been manic, you have bipolar I disorder. However, many people with bipolar I disorder will have had only depressive or mixed episodes, making the diagnosis trickier. This has important implications for screening and treatment, as we must do our best to find those people who, though depressed, should be more accurately diagnosed with bipolar depression as opposed to “regular,” or unipolar, depression.
Bipolar II disorder is defined by having had at least one depressive episode in addition to at least one hypomanic episode. If there has ever been a manic episode, then this diagnosis is superseded by that of bipolar I disorder.
Thus the crux of this diagnosis rests on the definition of a hypomanic episode:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
During the period of mood disturbance and increased energy and activity, 3 (or more) of the above symptoms (4 if the mood is only irritable) have persisted, represent a noticeable change from usual behavior, and have been present to a significant degree.
The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
The disturbance in mood and the change in functioning are observable by others.
The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.
If there are psychotic features, the episode is, by definition, manic.
The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment).
Note how much of this definition rests on functioning. Additionally, the 4-day cutoff is not necessarily based on any hard data, and is as such arbitrary. People may have this condition but experience hypomanic symptoms for only 2-3 days.
Cyclothymia, or cyclothymic disorder, is even trickier to diagnose. It is defined by numerous hypomanic and dysthymic (read: depressive, but not meeting criteria for a full major depressive episode) episodes over 2 years or more. These patients are not symptom free for periods longer than 2 months. If a patient ever meets criteria for major depression, mania, or hypomania, then this diagnosis is superseded.
How is the diagnosis made?
There is as of yet no single test, clinical tool, imaging study, or lab work that has been validated for making a diagnosis of any of the above conditions. They remain clinical diagnoses, only able to be made by qualified professionals through longitudinal observation, mental status exams, and thorough history-taking.
Bipolar Disorder vs. Unipolar Depression
The ability to clearly differentiate between bipolar and unipolar depression is one of the most important skills a psychiatrist can develop. Unipolar depression, which is what we mean when we say “depression” broadly, or Major Depressive Disorder clinically, is also episodic, but exclusively depressive. There are no periods of hypomania or mania.
The distinction is important because it directly impacts our choice of treatment. Unipolar depression is commonly treated with first-line antidepressants like SSRIs or SNRIs. In bipolar disorder, however, these medications are dangerous as they may precipitate mixed states or mania if used to treat bipolar depression. Thus we should do our best to separate these conditions out before initiating treatment.
Features suggestive, though not entirely indicative, of a depression being bipolar rather than unipolar:
- Earlier age of onset
- Multiple depressive episodes yearly
- Brief depressive episodes (3-6 months)
- Hallucinations, delusions, melancholia
- Strong family history of bipolar disorder
- History of non-response to SSRIs/SNRIs, or a worsening of their condition when on them (less strongly indicative)
It is an unfortunate feature of bipolar disorder that mania and hypomania are grossly underreported by patients due to poor insight. Hypomanic episodes may even be desirable as they are often experienced as productive or enjoyable. Thus, even if a patient denies a history of any of them, it is useful to speak with family or others who know them well, as they will usually report these signs and symptoms more accurately.
The fact is that without an obvious history of mania, bipolar disorder is hard to diagnose. This is why establishing a long term relationship with a psychiatrist is so important for the treatment of depression. The “system” wants to quickly prescribe SSRIs to anyone who self-presents as depressed. This inevitably leads to iatrogenic harm in a sizable portion of the population, as these medications lead to a worsening of the underlying condition in anyone with latent or undiagnosed bipolar disorder.
Bipolar Disorder vs. Personality Disorders
Here we must address the fact that the word “bipolar” has taken on much more than its true clinical meaning. Colloquially, “bipolar” is thrown around as a pejorative term, typically for people who are seen as moody or unstable. While mood lability is certainly a feature of bipolar disorder, especially in mixed or manic states, it is also the case that we see this with many other conditions.
Again, the timeline is important: with bipolar disorder, we are talking about changes in mood that are depressed, mixed, or manic, and sustained over many weeks. They are also associated with other signs and symptoms, such as changes in sleep patterns or the presence of hallucinations.
With borderline personality disorder (BPD), we are no longer dealing with an episodic condition. BPD is chronic, as is bipolar disorder, but there are no periods of remission in between episodes of BPD – indeed, there are no episodes at all.
Those with BPD can experience rapid and dramatic changes in their mood, but these are often instantaneous, in response to an external stimulus, and can just as quickly resolve when the situation changes. There are other features of BPD that are not necessarily present in bipolar disorder, such as chronic feelings of emptiness, repeated self-harm, and persistent thoughts of suicide. BPD also has a higher associated rate of a history of sexual abuse, suggesting that its genesis is more rooted in trauma and psychosocial factors than bipolar disorder, which is more biologically based.
It is important to note that these conditions are not mutually exclusive. One can have BPD and bipolar disorder. In these cases, patients are best served by treatment with a qualified psychiatrist well-versed in both conditions. Making both diagnoses is complicated and requires time more than anything else.
Treatment of BPD is therapy, and lots of it. The most commonly studied and used modality is Dialectical Behavioral Therapy (DBT), though with greater insight and emotional control these patients ultimately can benefit from psychodynamic psychotherapy as well.
While patients with bipolar disorder can benefit from psychotherapy, the treatment is almost exclusively biological, with an emphasis on the use of mood stabilizers as medication.
Executive Function, ADHD & Mood Dysregulation
Current psychiatric discourse, especially on social media, is dominated by discussions of autism, ADHD, and neurodiversity. It is as if everything related to psychiatry must be seen through these lenses. Unfortunately, this top of pop psychology only lends itself to misinformation, which can do real harm to our broader patient population.
I am including these issues here because at this stage, it is how many people process and perceive their own mental struggles. I have had a great many patients come to me with concerns about ADHD or other cognitive concerns like forgetfulness, inattention, or disorganization. They have decided on their diagnosis before we have even met. Once in a while they are correct, but more often than not there is something else afoot.
Issues of executive functioning, including poor concentration and distractibility, are core features of the major mood disorders, including unipolar depression and bipolar disorder.
Thus, we should remember that ADHD is a diagnosis of exclusion. If the signs of ADHD can also be explained by a depressive, mixed, or manic state, then we do not diagnose ADHD. The same goes for any substance use that is active, including cannabis.
Similarly, issues of executive functioning may be just that. Some people are just a bit disorganized or forgetful. This does not mean that they all have ADHD, a developmental condition that starts in childhood. They may benefit from some coaching or behavioral interventions.
With bipolar disorder, executive dysfunction may be more of a feature than a bug. Depression can cause poor concentration, a lack of interest or motivation, and a general dulling of one’s cognitive faculties. Mania can cause distractibility, as one can hardly keep up with the speed of one’s thoughts. This often leads to many projects happening simultaneously, all in a state of unfinished disarray.
Again, the major implications here are for treatment. To give someone with bipolar disorder a stimulant is akin to pouring kerosene on a bonfire, if your goal is to put out the fire. It makes no sense and only makes the underlying condition worse. Sure, the patient will almost certainly focus better for a time, but you have also just destabilized their bipolar disorder, making a mixed or manic episode all the more likely. People with bipolar disorder kill themselves when they are in active mood episodes. This is not something we should just do with a passive “watch and wait” attitude.
The real treatment of executive dysfunction in bipolar disorder is to treat the bipolar disorder. This may entail the use of mood stabilizers like lithium or second-generation antipsychotics if needed. It is an unfortunate truth that even if the mood is stabilized, executive dysfunction can persist in those with bipolar disorder. Sometimes this is related to medication effects, other times it is simply a feature of their disease. In these cases, therapeutic and behavioral interventions are the preferred modalities of treatment.
Therefore, while it is common to see patients who have been diagnosed with bipolar disorder and ADHD, this cannot really be true. They may have had ADHD as children, and indeed this is a risk factor for the development of bipolar disorder later in life. But adhering to the concept of a diagnostic hierarchy, the diagnosis of bipolar disorder supersedes that of ADHD. This directly impacts our choice of treatments. Otherwise you get the all-too-common scenario of someone taking both a stimulant (dopamine agonist) for ADHD and an antipsychotic (dopamine antagonist) for bipolar disorder, medications in direct competition with each other.
Sometimes less is more in psychiatry, and that is the case in this particular scenario.
High-Functioning Bipolar in Professionals
I carved out a specific section here to dispel some myths about bipolar disorder. Many people think of this disease as destroying lives, and it certainly can. But not everyone with bipolar disorder leads chaotic impulsive lives, nor do they wallow in bed, achieving nothing. With proper treatment, many people manage their bipolar disorder and lead long, healthy, and successful lives.
I have treated many professionals with bipolar disorder, including scientists, lawyers, and esteemed physician colleagues across many specialties. One thing they all have in common is the intellectual ability to suppress their bipolar disorder. They still experience the mood episodes, of course, but they are able to internalize it. They suffer no less, and maybe even more for it, and because of this tendency, their diagnosis and treatment is often delayed.
Many professionals willingly accept a diagnosis of ADHD, because the treatment is a stimulant that will then increase productivity. They may also even accept a diagnosis of depression – or should we call it burnout? – because this is less stigmatized than bipolar disorder. For those with true bipolar disorder, however, either of these approaches will lead to only further harm.
As discussed in previous sections, the use of standard antidepressants or stimulants in those with bipolar disorder is dangerous and often does more harm than good in the long run. That is why proper diagnosis is essential. A thorough psychiatric evaluation with careful screening may highlight features of bipolar disorder that were previously missed.
In short, professionals often shirk the possibility of having bipolar disorder, often to their own detriment. I would highlight, however, that many successful people across all walks of life have lived with bipolar disorder, and it may even be the case that the lived experience of this disorder leads to greater empathy and creativity.
If you are a professional, physicians included, concerned about possible bipolar disorder, or simply unsure if you have a diagnosis at all, please reach out through my confidential and HIPAA-compliant contact form.
Evidence-Based Medications for Bipolar Disorder
The treatment of bipolar disorder is complicated, and books have been written on the topic. Here I will aim to cover the topic in broad strokes, both in terms of what treatment should entail and what we should avoid.
Mood Stabilizers
Firstly, “mood stabilizer” is not a real class of drugs in the sense that none of them share a common mechanism of action (like all SSRIs do, for example). Psychiatrists use the term to refer to drugs which are appropriate to use in bipolar disorder in that they either treat or prevent mood episodes, while at the same time not worsening or precipitating others (again, like SSRIs).
Lithium – the Gold Standard
For bona fide bipolar I disorder, the gold standard remains good old lithium. In use since the 1930s, lithium is the most studied medication for bipolar disorder, yet remains underutilized and poorly understood by both the public and the medical field at large.
Lithium is a mood stabilizer. We can think of mood stabilizers as medications which are appropriate for depression, mania, and everything in between.
There is less guesswork when it comes to dosing lithium. Unlike many newer medications, we dose lithium based on a targeted blood level, which means that being on lithium entails getting period lab work.
More important than its ability to treat acute depression or mania is its role as a preventative agent. There is good evidence which shows that lithium reduces the frequency and severity of future mood episodes. When lithium works, it works well.
Additionally, lithium is proven effective for unipolar depression as well. Thus, if there is uncertainty about a diagnosis, or a high suspicion for undiagnosed bipolar disorder in a depressed individual, then lithium is a safer medication to use than an SSRI.
Lithium is one of only two medications (the other is clozapine for schizophrenia) that has been proven to directly reduce suicidality. Thus, lithium saves lives.
It can cause side effects like any other medication, which is why we obtain routine blood work. Tremor and thyroid issues are fairly common – both easily treatable. At higher levels, especially dangerously high levels, there can be confusion, dizziness, and kidney dysfunction. It is essential to tell your doctor about all medications you are taking to minimize the risks of this occurring.
Lithium has neuroprotective effects, apparently even at low or subtherapeutic doses. Studies have shown that it may prevent, or at least delay, the onset of dementia. Those with bipolar disorder already have a higher baseline risk for dementia, which is yet another reason to give lithium a try.
Not everyone responds to lithium, though everyone with bipolar disorder should at least try the medication, given the potentially massive upside if it works.
Lithium is a complicated drug, best managed by a qualified psychiatrist. It is impossible to include all information about it here in a short post, so if you have any questions about it, please reach out and schedule an appointment.
Lamotrigine
Perhaps the most commonly used mood stabilizer is lamotrigine (Lamictal). Unlike lithium, it does not require any blood work, making it a bit easier to deal with. Lamotrigine is also an antiepileptic medication, highlighting its ability to stabilize the brain.
Like lithium, lamotrigine’s role can be thought of as more preventative than acutely useful. It may be more effective at preventing future depressive episodes than manic ones.
Its side effect profile is relatively benign, though at higher doses many people experience a general cognitive slowing. This becomes more pronounced above 100mg daily. A very rare, but possible, side effect is Steven-Johnson Syndrome (SJS) which is a life threatening skin condition. If anyone on lamotrigine develops a rash – and about 10% will – they should notify their doctor immediately. Most often it is a benign rash, but again, very rarely it is SJS.
Lamotrigine interacts with oral contraceptives and may make them less effective. Make sure your doctor knows everything you are taking.
Valproate
Also called valproic acid or Depakote, valproate is the third of the major mood stabilizers. Like lithium, it requires blood work to monitor the liver and to maintain a steady blood level of the drug. Therefore we dose valproate based on the blood level, not by clinical response. That said, lower levels are often adequate for bipolar II disorder compared to bipolar I disorder.
It causes more weight gain than lithium, and can cause some other unsavory side effects which may scare people away from it, including hair loss. In women of reproductive age, we almost never use this medication because it greatly increases the risk of teratogenic effects in the fetus. It has good calming and anxiolytic effects, but many find it overly sedating.
Valproate is effective for treating mixed states in addition to its role as a preventative agent. It is likely used less commonly than the other two because of its side effect profile and teratogenicity.
Carbamazepine
Carbamazepine (Tegretol) is a useful mood stabilizer, and causes much less weight gain than valproate. Its effects do not seem to be as robust as lithium or valproate, though it is still a useful medication.
While we do not obtain routine drug levels, it is recommended to get periodic blood work to monitor the liver and blood counts. It interacts with many drugs, and so is often not a good option for many older people who take other medications. For younger or healthier people, it is a good option, especially if it can be paired with lithium.
Antipsychotics
These medications have unfortunately been the victims of bad nomenclature. We should probably call them dopamine blockers, as their effects are much greater than simply treating active psychosis. Indeed, one need not be psychotic to benefit from them.
For bipolar disorder, they are naturally most useful when psychotic features are present, whether that be in the depressive or manic state. They are still useful without psychotic features, however, especially to bring down a manic episode.
A few have received specific FDA approvals for bipolar depression. These include:
- Quetiapine (Seroquel)
- Lurasidone (Latuda)
- Cariprazine (Vraylar)
- Lumateperone (Caplyta)
- Olanzapine-fluoxetine combo (Symbax) — Note here that fluoxetine, an SSRI, is safe to use when combined with olanzapine (Zyprexa)
Note that these are the ones with a specific FDA approval. We frequently use other agents off-label for similar purposes when needed.
These are all second-generation antipsychotics (SGAs) which come with high rates of weight gain and subsequent metabolic syndrome. As such, they should be used judiciously and not blindly continued indefinitely, even if they were effective in the acute phase. For maintenance and prevention, mood stabilizers are more appropriate.
Benzodiazepines
While they should never be used for long term maintenance treatment, benzodiazepines can have a role to play in the treatment of bipolar disorder. These include alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin; often preferred due to its longer duration of action). Their anxiolytic and sedating qualities are particularly useful in the treatment of manic or mixed states.
For catatonia, a severe presentation of bipolar disorder, they are the treatment of choice; this is almost exclusively done in inpatient settings and at high doses.
The use of benzodiazepines should be judicious and short, whenever possible. They are controlled medications which carry a risk of abuse, tolerance and dependence, and are linked to longer term cognitive deficits.
That said, they are potent and quite effective, and work immediately, as opposed to the weeks or months it may take other classes of medications to be effective.
Other Classes of Medications and Treatments
The above are the only medications that have a real place in the treatment of bipolar disorder. SSRIs and SNRIs, tricyclics (TCAs), bupropion (Wellbutrin) and stimulants should all be avoided, as they can precipitate more rapid cycling if not frank mania.
Other more interventional treatments include electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). Both can be effective in certain situations, though naturally they are a very different type of treatment, requiring regular visits to an office for the procedure.
Circadian Rhythms, Sleep, & Episode Prevention
Sleep is key when dealing with bipolar disorder, as individuals with the disease are particularly sensitive to changes and perturbations of their circadian rhythms. As such, sleep should always be prioritized and protected.
Broadly speaking, purely depressive episodes tend to come with hypersomnia, or an increased need for sleep. Manic episodes reflect a decreased need for sleep. Sometimes, when manic, people may not sleep at all for days on end, seemingly with endless energy. Mixed states have their own sleep problems, such as in an agitated depression, when someone both feels an increased need to sleep, yet is restless and unable to do so.
Even within the scope of bipolar disorder, physical or medical causes of sleep disturbances should always be ruled out when appropriate. This may involve referral for a sleep study to rule out conditions like sleep apnea or narcolepsy.
Within bipolar disorder, especially during acute mood episodes when sleep becomes elusive, medications can be used. The first step should be to consolidate medications to nighttime dosing if appropriate, to maximize any sedating effects.
If an additional medication is needed, then a second-generation antipsychotic is often a good choice. Commonly this is quetiapine (Seroquel), but many others can be used for their sedating properties, such as olanzapine or risperidone.
If it is preferable to avoid an antipsychotic for whatever reason, or the patient has found them intolerable, then judicious use of a benzodiazepine may be warranted. For short-term use on the order of days to weeks, benzodiazepines can be used safely and effectively to contain sleep in bipolar disorder.
Outside of medications, behavioral interventions should always be implemented. Standard sleep hygiene, such as avoiding late-day caffeine and minimizing screen time around bedtime, should be implemented. Other therapeutic modalities such as CBT-i (for insomnia) can help.
Maintaining good sleep habits and patterns is essential in the prevention of future mood episodes. This is partially why bipolar disorder tends to flare up in the fall and spring as seasons change – sunlight hours and therefore circadian rhythms change, too.
Shift workers and those who travel across time zones for work frequently are at greater risk of sleep disturbances. This is important because those with bipolar disorder may want to avoid careers that do not lend themselves to regular, routine sleep.
Good sleep is important for everyone, but for those with bipolar disorder, it is of paramount importance.
Co-Occurring Anxiety, Substance Use, & Trauma
Bipolar disorder does not always present independently, as we have discussed previously regarding borderline personality disorder. Other conditions with high rates of comorbidity with bipolar disorder include anxiety disorders, substance use disorders, and PTSD.
Anxiety
Anxiety is a bit like headache or fever in the world of psychiatry: common, nonspecific, important to note, but not always the diagnosis in and of itself. Just like a fever can mean multiple things like infection, cancer, sepsis, etc., so too can anxiety relate to a host of conditions.
Issues with anxiety are almost par for the course when it comes to bipolar disorder. They may even rise to the level of meeting diagnostic criteria fully on their own. Yet here is where the concept of a diagnostic hierarchy is important. What is the standard medical treatment of a condition like Generalized Anxiety Disorder (GAD)? An SSRI, typically at a higher dosage. Blindly treating anxiety like this in someone who has bipolar disorder would be disastrous. Thus, the bipolar disorder supersedes whatever anxiety disorder may or not be present.
Any symptoms of anxiety should be seen within the context of bipolar disorder or the person’s psychosocial situation. Yes, some anxiety is appropriate and better addressed through therapy. Yet if it is persistent, or without clear instigation, then it is worth exploring their bipolar disorder more broadly. Anxiety may be the canary in the coal mine, an initial indicator of an impending mood episode. It is present more often than not in mixed episodes.
Thus, the treatment of anxiety in bipolar disorder is completely different from a standalone anxiety disorder. We must address the bipolar disorder and any underlying perturbations in mood state, while also exploring the root and cause of the anxiety in a therapeutic way.
Substance Use
Rates of substance use in bipolar disorder are quite high, perhaps more than 50% over the lifetime. This complicates things because by definition, a diagnosis of bipolar disorder cannot be officially made if the signs and symptoms were caused by a substance.
A substance-induced mood episode may point to a preexisting propensity for these mood episodes, however, including latent bipolar disorder. Not everyone who uses cannabis daily will become manic or psychotic, yet those with bipolar disorder do at higher rates, whether they know they have bipolar disorder or not.
Others may use substances to self-medicate, intentionally or not. Alcohol and benzodiazepines can provide calming effects to those experiencing mixed or manic episodes, or temporary euphoria to those who are depressed. It is easy to see how this can lead to a substance use disorder down the line, if someone has mood episodes not infrequently.
In a situation where someone actively has both bipolar disorder and a substance use disorder, we simply have to treat both simultaneously. The treatment algorithm for bipolar disorder remains the same, though careful consideration should be given to avoiding medications with abuse potential. Psychoeducation is paramount, so that patients know how their substance use affects their mental health.
Trauma
Many patients with bipolar disorder have a history of trauma, sexual or otherwise, as discussed above regarding borderline personality disorder. Yet the rates of trauma in bipolar disorder are significantly lower than in BPD. Bipolar disorder has a clear biological basis, whereas with other conditions related to trauma like BPD, PTSD, or c-PTSD, the biology is less apparent.
So, like anyone else, those with bipolar disorder can experience trauma. Sometimes the trauma is self-induced, only to be realized and appreciated after a manic episode has resolved. “I did what?!” Other times, the past trauma is incorporated into the patient’s thinking, either becoming a depressive rumination or a manic delusion.
In all cases, particular sensitivity should be shown towards these patients. Psychotherapy can help patients develop better insight into their trauma, so that when they do experience a mood episode, it is less likely to come to the forefront of their thinking.
Out-of-Network Private Psychiatric Care
Bipolar disorder is a diagnosis that should only be managed by a qualified psychiatrist. Primary care doctors and other mental health professionals all have roles to play in these patients’ care, but the treatment must be directed by a psychiatrist well-versed in the diagnosis and management of this condition.
A psychiatrist in private practice is able to devote more time and attention to managing bipolar disorder. Insurance companies often restrict or limit appointment times, treatments, or otherwise try to influence care in ways that are not always in the patient’s best interests. In short, with a private psychiatrist, you pay more up front, but the care you receive should more than make up for that cost.
Additionally, for those with bipolar disorder, developing a relationship with a psychiatrist who knows you well is the single best investment you can make for yourself. When your doctor knows you, they will be better able to recognize when you may be in a mood episode, or when one is brewing. They will be less likely to assume you are on drugs or personality disordered if you present in distress during a mixed or manic episode. The benefits of longitudinal care for bipolar disorder are myriad.
In short, if you have bipolar disorder of any type, or are concerned that you might and are looking for a more thorough evaluation, then do not hesitate to reach out and schedule an appointment.