Brett Stevens has lived through the worst of bipolar and come out standing. Here’s what he did to get his life back. This is the first edition of The Pocket Psychiatrist, a monthly series you can share with your patients through a separate podcast stream
Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. I’m Chris Aiken, the editor in chief of the Carlat Report. And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
What is Bipolar Disorder?
KELLIE NEWSOME: Most mental health problems go by names that pretty much tell you what they are. Generalized Anxiety Disorder means you can’t stop worrying; Attention Deficit Disorder means you’re easily distracted and can’t pay attention; and Depression means your energy and motivation have sunk to a painful low. But Bipolar Disorder is not what it sounds like, and that’s part of the reason that so much stigma and misunderstanding surrounds it.
Bipolar disorder is a mood disorder where people cycle through periods of high and low energy. The low energy states are called depression. The high energy states are called mania when extreme, and hypomania – which means a little manic – when they are mild.
There are two types of bipolar, type 1 and 2. And whether your highs go all the way to mania or stop short at hypomania tells us which one of these you have, so that distinction is pretty important. Bipolar I means you’ve had a full mania – even if you’ve only had 1 – while bipolar II means you’re highs have only gone to the hypomanic level. Nearly everyone with bipolar I or bipolar II has also had depression, but we’ll get into that later.
Mania and hypomania are both states of high energy where the volume is turned up on everything.
Thoughts move quicker, speech is louder, you are restless, hyper, and move around a lot. Ideas and plans come easily, so you take on more than you can chew. You’re also quick to react and can cycle through 15 emotions in 5 minutes. And you’re quick to react – even acting on impulse, doing things you might regret. Things like starting – or ending –relationships; buying clothes that never get worn; flirting with coworkers; aggressive driving; skipping class; giving lots of presents; or walking alone downtown at 3 in the morning, unaware of the danger.
CHRIS AIKEN: What really marks the difference between mania and hypomania is just how risky and destructive that impulsivity gets. During mania, people do things that are difficult to repair, while in hypomania the things they do can usually be cleaned up after the fact. Here are some examples….
- Buying a car…. You can’t take it back, so that’s mania.
- Spending $300 on home decorations you don’t need but saving the receipt; that’s hypomania
- Losing your job because you cussed out your boss; that’s mania.
- Yelling at a coworker but patching it up with an apology the next day; that’s hypomania.
- Going into “road rage” so bad that you chase someone off the road, get in a fight, and end up in jail. That’s mania.
- Driving so fast you get a speeding ticket…. That’s hypomania
[Brett Stevens story of cars]
Mania also tends to go on longer – at least a week – while hypomania lasts at least 4 days… and all the other symptoms, like the hyped up energy, are more intense during manic states.
Today Brett Stevens talks with us about his experience with bipolar I disorder. He has written two books on what mania looks like and how to move beyond it. Bipolar tends to start in the teenage years, between age 15-20, and it can come on as a mania or depression. For Brett, it began with mania, and it came on fast:
[Brett Stevens quote]
CHRIS AIKEN: It took a little while for the doctors to figure out Brett’s diagnosis. That’s not unusual. On average, it takes about 10 years and 3 visits to mental health professionals to arrive at a correct diagnosis of bipolar disorder. When it first comes on, it may look like depression, or even anxiety or attention deficit hyperactivity disorder (ADHD). The tell-tale manic episodes might not start until later, or they may be mild – as in hypomania – and easily forgotten because they didn’t cause much of a problem.
Drug use can also confuse the picture, as it did for Brett. Brett was using drugs before his first episode, so the doctors were hopeful that it was a bad reaction to drugs that would go away. But his third episode came on without any drug use, and that’s when he was finally told about the diagnosis.
[Brett Stevens quote]
Ten years is too long to wait to get an accurate diagnosis, and there are things you can do to speed up the process. It sounds simple, but a paper-and-pencil rating scale is helpful in making the diagnosis. Google Mood Disorder Questionnaire for a popular one, or go to moodtreatmentcenter.com/measurement. You can also have a family member fill one out one from their viewpoint….
KELLIE NEWSOME: Please make sure that you haven’t had an argument with them prior to them filling that out. Try and find out as much as you can about any psychiatric problems that might run in the family. You know, families don’t often talk about all this but you can still learn a lot even if you don’t know their exact diagnosis – did anyone have signs of depression and mania that were misunderstood as anger, addiction, or personality problems?
What Causes Bipolar Disorder?
CHRIS AIKEN: Bipolar disorder tends to run in families, and it’s caused by a mix of genes and environment. There’s not one gene for bipolar – there are several dozen – and it’s not fair to call them bipolar genes because they do a lot else, and they can do a lot of good. They don’t even cause bipolar unless they get turned on – activated – by stress in the environment. Here are some of the top stressors that can flip these genes the wrong way:
- Drug use, including recreational drugs like cocaine or marijuana, but also drugs that doctors prescribe like stimulants and antidepressants.
- Stress, particularly a lot of intense fighting in the family
- Medical problems, especially infections that affect the brain or head injuries
- Anything that disrupts sleep, including shift work, electronic light at night and travel across 2 or more time-zones.
Actually those stresses can cause any mental illness, but the last one – sleep disruption – is the one that’s pretty unique to bipolar. You see, the main genes that cause bipolar are the same ones that program the body’s internal clock, or circadian rhythm. The circadian rhythm keeps mental and physical functions like sleep, appetite, concentration, and energy running on a 24 hour clock; so we sleep at night, wake up in the morning, and feel alert and motivated during the daytime when we need to.
Those are also the symptoms that breakdown during bipolar disorder. Mania revs up energy, motivation, and physical and mental speed, and turns down sleep so people keep going even on 4 hours of sleep. Depression turns down – or depresses – energy, concentration, and motivation; muscles move slower and time feels like it stretches on longer. Appetite can go up or down during these states.
Many of these symptoms are similar to what we see during jet lag, and bipolar and jet lag have the same biological cause – a breakdown in the body’s internal clock. As a doctor, I often find myself frustrated with this word “bipolar” – which doesn’t do a very good job of capturing what it’s like to live with this disorder. “Bipolar” means two poles – mania and depression – but people with this disorder live with other poles that cause pretty significant problems. There are mixed states, where mania and depression overlap, creating intense anxiety, physical tension, and agitated, irritable depression. There’s also the cognitive pole – bipolar can make people have concentration problems that look a lot like ADHD even when they are not in a mania or a depression.
For better or worse, the medical term for all this is “bipolar,” but I prefer the word Fragile Circadian Rhythm Disorder. That tells you more about the cause, and it points toward a solution.
KELLIE NEWSOME: When we say that bipolar like a severe form of jet lag, it’s not just an analogy. One of the top triggers of mania and depression is flying across two or more time zones, because the sudden shift in sleep, sunrise, and sunset takes a toll on an already fragile circadian rhythm.
So if your circadian rhythm is fragile, what can you do to take care of it? The answer is to do some simple things at the same time each day. Things like exercise, meals, daily routines, turning the lights down at night, and – most importantly – getting out of bed at a regular time. All of those things help set the body’s internal timekeeper, and when people get into those regular rhythm they have half as many episodes of mania and depression. It’s powerful medicine.
Brett found that a morning routine and waking up at regular times was important, but what about going to bed at regular times? That would help, but we don’t stress that because you have a lot less control over when you fall asleep. The best you can do is have a wind down routine that you do at a regular time. Dim, yellow lights; soothing music; relaxing activity; meditation; stretching; aromatherapy with scents like lavender; a hot bath are all good ideas.
Join us next month for part II in this series, where we talk with Brett about what helped him through the depressed part of bipolar.
KELLIE NEWSOME: Brett Stevens’ is the author of Crossover: A Look inside a Manic Mind, and the follow up book Crossing Back Over: The Practice of Owning and Accepting Bipolar Disorder, both released in 2020.
If you’re looking for help with bipolar, here’s a good place to start. The Depression and Bipolar Support Alliance has local chapters in most cities, and the people who go to those meetings have a pretty good sense of which providers in their community are skilled at working with bipolar disorder. Go to www.dbsalliance.org to find your local chapter, or start your own if you don’t see one there.
KELLIE NEWSOME: If you liked this podcast, well thank you – it’s the first in the series – spread the word and leave us a review in your Apple store.
CHRIS AIKEN: The Carlat Report is an independent publisher of all things psychiatric. Its books, journals, and podcasts have operated free of advertising and pharmaceutical industry support since 2003.