Putting the science in fiction - Dan Koboldt, Chuck Wendig 2018
Bipolar disorder
The brain is wider than the sky
By Jonathan Peeples
As a psychiatrist, I treat all types of mental illness. There are plenty of popular misconceptions about what mental illness looks like, but there seems to be more confusion surrounding bipolar disorder than any other condition. I work in the emergency department of a hospital, and nearly half the patients I see tell me they’ve been diagnosed with bipolar disorder by a provider in the past, but most of the time the patient is suffering from something else entirely.
Since I started writing, I’ve become more interested in how psychiatric conditions are portrayed in fiction. I went to a local bookstore recently and asked for recommendations of young adult novels that contain elements of mental illness. An employee suggested Rainbow Rowell’s Fangirl (St. Martin’s Press, 2013), which turned out to be the highlight of my Thanksgiving season. I loved it. I sat down and devoured it like it was my mom’s green bean casserole. The main character’s father suffers from bipolar disorder, and Rowell does a wonderful job showing what this can look like. She accurately describes manic symptoms and demonstrates a solid understanding of how the illness can impact friends and family members. The only problem is that I wasn’t expecting to read about a character with bipolar disorder because the bookstore employee thought the father was suffering from obsessive-compulsive disorder.
Let’s take a closer look at bipolar disorder.
Is bipolar disorder the same thing as mood swings?
Nope. This seems to be one of the most common misconceptions. Patients often come in and tell me that they have bipolar disorder because their mood can change from one minute to the next and the smallest thing can set them off. True bipolar spectrum disorders involve manic, hypomanic, and depressive episodes (see next section) that last for days at a time.
What most patients with these minute-to-minute “mood swings” are actually experiencing is mood dysregulation associated with their personality structure and primitive defense mechanisms. This doesn’t mean that these patients are any less sick, but making the correct diagnosis has tremendous implications for treatment. Patients with bipolar disorder almost always need medications to control their symptoms over time, whereas for patients suffering from the mood dysregulation described earlier, therapy is the mainstay of treatment.
Mood dysregulation isn’t an actual diagnosis, though it’s a symptom commonly seen in personality disorders such as borderline personality disorder. It’d take years to fully discuss all the theories of personality structure, but I’ll give an example of how it might develop.
Imagine a child living in an abusive household. He’s new to the world, and his life has been chaotic since birth. Whenever he feels threatened, he’ll fight back or scream or run away—whatever it takes to protect himself. Sometimes these primitive defenses work, and the behaviors are reinforced. Eventually, he grows up and moves out of his childhood home. He’s no longer being abused, but when he faces the stressors of everyday life, he doesn’t know how to respond except to use the same defenses he developed as a child. Screaming and fighting over minor insults leads to a pervasive instability in his adult relationships and often contributes to feelings of depression or dissatisfaction.
If you’re going to write a character who has mood swings like those described, call it borderline personality disorder, not bipolar disorder.
Manic, hypomanic, and major depressive episodes
Now we’re getting to the heart of it. What’s important to point out is that to qualify for any of the following episodes, the collection of the symptoms must be associated with a change in previous functioning and can’t be due to substance use or another medical condition.
Manic Episodes
To have a manic episode, a person must have either elevated, expansive, or irritable mood AND increased goal-directed activity or energy. There’s a great example of this behavior in Fangirl. The main character’s father calls her in the middle of the night because he’s not sleeping and has plans to install a fireman’s pole to connect the upstairs bathroom to her bedroom. People may also experience grandiosity, pressured speech, a decreased need for sleep, distractibility, and engaging in harmful activities. A manic episode must last at least seven days unless the person experiencing it has psychosis or needs hospitalization during the first week of symptom onset. A manic episode must be severe enough to cause impairment in social or occupational functioning.
Hypomanic Episodes
A hypomanic episode has similar symptoms to a manic episode, but the symptoms only need to last for four days. Other people are going to notice changes in the person’s behavior, but unlike manic episodes, hypomanic episodes aren’t severe enough to cause a serious impairment in social or occupational function.
Major Depressive Episodes
A major depressive episode must have depressed mood AND loss of interest and pleasure for two weeks in a row. You also may see fluctuations in weight (more often weight loss), insomnia or hypersomnia, fatigue, guilt, feelings of worthlessness, and thoughts about death. The symptoms need to be severe enough to cause impairment.
Types of bipolar disorder
There are several variations of bipolar disorder, but the two major ones are bipolar I and bipolar II. To be diagnosed with bipolar I, you must have had a manic episode. Patients with bipolar I often have hypomanic and major depressive episodes as well, but these aren’t required for the diagnosis. To be diagnosed with bipolar II, you cannot have had a manic episode, but you must have had both a hypomanic episode and a major depressive episode.
Other diagnoses on the bipolar spectrum include cyclothymic disorder and substance/medication-induced bipolar and related disorders. Manic and hypomanic episodes can be mimicked by illicit substances such as cocaine and methamphetamines. Sometimes, prescribed medications such as steroids or stimulants (e.g., Vyvanse, Adderall) can lead to manic behavior.
Who Gets Bipolar Disorder?
Bipolar disorder is present in about 1 percent of the general population worldwide, but it’s more common in high-income countries. It’s slightly more prevalent in men. There’s a strong genetic component, and relatives of people with either schizophrenia or bipolar disorder have an increased chance of developing bipolar disorder.
The onset of bipolar I is about age eighteen, and the onset for bipolar II is in the mid-twenties. Bipolar disorder often isn’t diagnosed until years after its onset because it can look like major depressive disorder or other conditions. Most people spend more time in a depressed state than a manic state, but the amount of time varies widely from person to person. There are also periods when people don’t qualify for any type of mood episode and are relatively stable. There are many commonly co-occurring mental disorders including anxiety disorder, conduct disorder, and substance use disorders.
Treatments for Bipolar Disorder
There are many agents available to treat bipolar disorder, and it often comes down to the doctor discussing the risks and benefits of each agent with the patient and reaching a mutual decision.
Lithium and valproic acid are two agents that control mania well. It’s important to periodically check blood levels of these medications to ensure the patient is receiving enough of the medication without causing toxicity. Lithium also has an antidepressant effect and has been shown to decrease suicidality in certain populations. Valproic acid is thought to have an antidepressant effect as well, though the data for this aren’t as robust.
Giving someone with bipolar disorder an antidepressant increases the risk of developing a manic episode, even if the person is on a therapeutic dose of lithium or valproic acid. That said, since many people with bipolar disorder spend significant time in a depressed state, antidepressant use in patients with bipolar disorder is a common practice. Some people agree with this practice while others don’t, but it’s worth knowing it’s out there.
Antipsychotics are often used in acute manic episodes, but some can also be used long-term or for depression. The three drugs approved by the U.S. Food and Drug Administration for bipolar depression are Latuda, Seroquel, and Symbyax. Lamictal is a mood stabilizer that doesn’t control mania as well as lithium or valproic acid but is commonly used for bipolar depression.
How to apply this to writing
If you’ve considered creating a character with bipolar disorder, I hope this information is helpful in guiding you through that process. The most important thing to recognize is that the “mood swings” seen in bipolar disorder are sustained periods of elevated or depressed mood, not something that changes from one minute to the next. Your character will probably have other family members with mental health diagnoses such as bipolar disorder or schizophrenia, and the character will usually develop the condition in her late teens or early twenties. Medications can be helpful in controlling symptoms, but people often don’t like taking them because of the side effects or “feeling numb.” Unfortunately, many people decompensate without medication.
Toward the end of Fangirl, I was worried that the main character was going to develop bipolar disorder like her father. She was the right age, and there was occasional decreased need for sleep and increase in goal directed activity. I don’t know if Rowell wrote it that way on purpose, but it certainly added to the tension when I read it. By describing mental illness accurately, she made it much easier for me to buy into her story and to enjoy it from beginning to end. A little bit of research can go a long way in making your story believable.