Bipolar I: A Case Study
Josh Scott – MANAGING EDITOR
“Earlier Dan said to me what are you on I want some and I’m like OMG no you don’t this is f***ing torture but actually I just said no,” writes Cadie, mid-manic episode.
Cadie is a second-year student at the University of Toronto. She has courageously chosen to share her story in the hopes that it will raise awareness of and about her condition. Should it make even a single person feel a little less alone, she’ll consider it a bonus. Remarkably sweet, bright, and strong beyond her years, Cadie was diagnosed with bipolar disorder type I — for short, bipolar I — in 2015. However, as you might already suspect, it wasn’t as simple as that.
Cadie, of course, is her name for sake of anonymity. It’s an homage to the daring Aussie doctor John Cade, whose 1949 kitchen experiments are credited with having revived the use of lithium in psychiatry — lithium being the mood stabilizing wonder-drug that has allowed her to balance her emotions and by extension, her life.
Cadie first knew she was different in grade 7. She recalls a conversation in which a friend recounted having overcome a fear through sharing her feelings with someone she trusted. While the ability to do so might have come naturally to the friend, it never has for Cadie. Even now, she finds it incredibly difficult to talk about her feelings. She describes having felt that, since “nothing bad” had happened to her, she “didn’t deserve help.”
One of the most harrowing and informative accounts of a life lived with bipolar disorder, is Dr. Kay Redfield Jamison’s breathtaking memoir An Unquiet Mind. Jamison writes on bipolar disorder from perspectives both clinical and personal — she herself has contended with the illness from the age of 17.
It is a sad truth that people are often too caught up in their own lives to notice when others are hurting. As Dr. Jamison keenly observes, this is especially true when those hurting make efforts to disguise their pain. She had been led, by a variety of factors, to believe that people were supposed to keep their problems to themselves.
Cadie’s full diagnostic history is long and convoluted. In 2011, following a straining overseas exchange, she was diagnosed with anxiety and prescribed anti-anxiety medication. In 2013, she was diagnosed with mild-depression — something she believes herself to have suffered with for years — taken off her anti-anxiety medication and prescribed anti-depressants. In 2015, she was diagnosed as bipolar, taken off anti-depressants, and prescribed mood stabilizers.
Once told by an oblivious doctor that she was “damaged”, Cadie recalls wishing at the time, that she “had a broken bone that could be fixed.”
Bipolar disorder is an “episodic” (that is, recurrent) mood disorder typically made up of three states. These states range from high (mania) to low (depression). Between high and low, there also exists a middle, so-called “well” state, in which the person may function properly and feel normal. For some, all three states are mixed — these people experience episodes in which symptoms of both mania and depression occur simultaneously. The order and frequency of each is unpredictable.
The bipolar navigate the extremes of the emotional spectrum for what seems like no discernible reason. Evidence suggests biological, genetic factors are partly to blame. However, it is more than, as some would suggest, a mere imbalance of neurotransmitters (like dopamine or serotonin). Nor is it caused by stress.
Though stress doesn’t cause bipolar disorder, it may trigger manic or depressive episodes in someone who already suffers from it. Triggers can also be chemical: take, for example, anti-depressants.
The issue of medication is also tricky: specifically, finding the proper dosage. As Cadie says, “it can take years to figure out what exact ‘cocktail’ of medications work for a specific patient.” On the part of the patient, a sort of blind faith (in the clinical process of trial-and-error — to this date, the best method) is required.
It is common for bipolar disorder to be mistaken for depression. It’s no stretch to see how — on average, 1 in 6 people will experience depression firsthand. While doctors are correct in diagnosing depression, it often takes time for them to notice that a patient’s depression is actually an aspect of something larger (i.e., bipolar disorder).
You see, one of the main problems with this trial-and-error process is that those with bipolar disorder tend to respond poorly to anti-depressants. Cadie’s depression led to her first and only suicide attempt, the summer following grade 11. For her depression, she was prescribed anti-depressants. These anti-depressants triggered an episode of depression in which she displayed psychotic symptoms in 2013 — in which she believed that she wasn’t a good person and had hurt everyone around her. This was during grade 12, and caused her to miss six straight weeks of school. (Might I add that she nonetheless graduated on time and with exceptional marks.)
Other factors are also at play. According to a 2016 study published in the Canadian Journal of Psychiatry from the University of New South Wales there is, on average, a six-year gap between the onset and diagnosis of bipolar disorder.
Though it is gradually becoming more common for teens to be diagnosed with bipolar disorder, historically speaking, it is not uncommon for the signs of bipolar disorder to be mistaken for typical adolescent behaviours. Basically — those suffering are taken as moody teenagers and, as such, their symptoms are discounted or ignored.
Cadie found that, of the people in her cognitive behavioural therapy (CBT) group, she was among the youngest. Several were 50-plus, and many shared that they had only recently been diagnosed. One older man told her that bipolar disorder had ruined his life. A large amount of them had received treatment for various other diagnoses, including but not limited to, depression.
We all experience mood swings, to varying degrees. We each attribute different levels of significance to them. Often, they depend on external factors, if social, environmental or otherwise. They can also depend on internal factors — which in turn, tend to concern our own reasoning or decision-making processes. Regardless of whether or not they seem warranted, for most of us, the root cause of these moods is either already apparent or at the very least, easily traceable. Among other things, this ability to recognize the source of our feelings differentiates us from those suffering from bipolar disorder.
Cadie alludes to having felt a basic disconnect during her full-blown manic episode. Imagine this: all of a sudden, everyone around you starts reacting in ways that don’t quite seem to line up with the way you feel you’re acting. Only, in this case, your brain — for most of us, a refuge or asset in situations like this — Is neither. You’ve lost the reins and yet remain subject to the whims of your thoughts and feelings. Everything seems really exciting and you feel good. On some level, you recognize that there’s a problem, but you lack the capacity to identify it. You know something’s wrong, but you can’t quite put your finger on what, and are powerless to do anything about it.
In the midst of her manic episode, she recalls making a practice of buying nice (i.e., expensive) watches and giving them away to total strangers, whom she struck up conversations with on the street. But one of a string of poor financial decisions with long-term ramifications, for her, doing so seemed perfectly sensible at the time. Thankfully, in hindsight, she is able to appreciate the absurdity.
However, she expresses remorse for the relationships she believes herself to have damaged. “There were people that, afterwards, I was too embarrassed to approach, and haven’t connected with since,” she says.
“Sometimes I feel like history is just repeating myself and I really tried to do stuff today but I couldn’t cross anything off my list I am so so sorry I am like this please don’t be mad I used to feel so different and I wanted something medical to stand out and this must be karma and I am an idiot but I need help,” writes Cadie, mid-manic episode.
People in the midst of a manic episode must meet three or more of the following criteria, as laid out in DSM V: feelings of grandeur, less need for sleep, increased talking, racing thoughts, sped-up activity, poor judgment, and/or psychotic symptoms. Hypomania, while milder by definition, nonetheless requires treatment—as it runs the risk of progressing to mania. These symptoms must last at least 7 days. To dispense with a common misconception, not all who experience a manic episode feel happy or euphoric: some feel irritable, angry, and/or aggressive.
On the other end of the spectrum, those suffering from depression must experience five or more of the following: depressed mood, marked loss of interest in pleasurable activities, weight loss/gain, insomnia/hypersomnia, apathy/agitation, loss of energy, feelings of guilt/worthlessness, indecisiveness/inability to concentrate, suicidal thoughts, and/or psychotic symptoms. These symptoms must last at least 2 weeks.
Bipolar disorder is perhaps more prevalent than you might think. Worldwide, 1-2% of adults suffer from it. While no small portion on its own, additionally, countless others are indirectly affected.
Psychotherapy, while useful in treating bipolar disorder, is no substitute for medication. It is only effective when deployed in tandem with mood stabilizers like lithium. Though there are a variety of available treatments, most are medication-based. Cadie was forced to see a psychotherapist regularly, which made her less inclined to be open. Given that, in any form of therapy, much depends upon your own willingness to share, psychotherapy wasn’t very effective for her.
In the midst of severe episodes, those suffering from bipolar disorder often require hospitalization. Guidelines in such cases are inexact. This determination to hospitalize someone is made once that person begins to seriously risk the well-being of themselves or persons around them. Cadie’s admission to CAMH in May of 2015, during her full-blown manic episode, had initially been against her will — a doctor had intervened and signed a form that forced her to stay for 48 hours. Only afterwards did her stay become voluntary.
Cadie’s stay lasted two weeks. Her roommate, also bipolar I, was manic as well. She had been there for over a month — her medication had made little to no difference. For Cadie, seeing an exaggerated version of herself was incredibly scary. At times, her roommate was even too much for her to handle. Cadie came to CAMH after her, and was released before her. When they crossed paths again, when Cadie returned for CBT group therapy, her former roommate had become depressed.
Most of the other patients seemed to either be schizophrenic, bipolar or depressed (depression as distinct from bipolar). One man told her stories of how he had written a calculus textbook and built a two-mile long fortress that was impenetrable. She found that people were generally pretty open about their diagnoses.
As of yet, there is no cure for bipolar disorder. Clinical knowledge and understanding, at best, permit bipolar disorder to be managed and controlled effectively.
On a practical note, for fellow students that are suffering: Cadie’s experiences with accessibility services have been positive. However, as she’s learned through experience and now wishes to relate, the lovely people at accessibility services are unable to meet you halfway. The onus is first on you to reach out — as it is logistically impossible for them to seek you out. She also recommends anticipating potential problems before they occur, as arrangements take time. If that sounds tricky, that’s because it is. To put it simply, don’t be afraid to ask for help, and learn to recognize your signs and potential triggers.
On a personal note, for the rest of us, confronting mental illness in a person you care about is much easier said than done. It’s easy to feel frustrated and helpless when that someone is acting and thinking irrationally. In most cases, as much as you might want to help, there’s not much you can do, save for offer your patience and understanding. But patience and understanding are nonetheless, vital.
Be there for the person (but, in the case of someone suffering a manic episode, don’t play into or encourage their excitement). Maintain an open mind and let them know that they can always come to you if they need someone to talk to. Having someone to talk to is integral. With a little knowledge, patience, and understanding, we can all be that someone.
If somebody you know looks like they’re hurting, but seems too afraid to admit or talk openly about it, ask them if they’re okay. If that person’s anything like Cadie, your asking could end up being just what they need.