Case Study: Ms. N was a 30 year old attorney who was referred to me by her treating psychiatrist for consultation. She had a long history of depression and anxiety. Her psychiatrist had treated her with a combination of psychotherapy and antidepressants.
Her recent response to Lexapro was an almost “too rapid” improvement followed by the “worst depression of my life,” when she could not sleep, cried endlessly, and even seriously considered killing herself for the first time. She had dreaded the onset of winter since childhood, her depression felt overwhelming in the week before her period, and she described the main problem of her mood as being its “swinging” in an unpredictable way.
She described multiple family members one or two generations removed who either had drinking problems (as she struggled with at times), or had ceased to function as a symptom of psychiatric illness.
Her history suggested the possible diagnosis of bipolar disorder because of the following features: a profound seasonal component, lability as the primary mood complaint, a history during college of short periods of hypomania, and a jarring “positive” response to SRI treatment.
When I brought up the possibility of bipolar disorder and treatment with lithium, she responded by saying, “Oh my God, are you serious? Isn’t that for people at Bellevue? Am I really nuts?”
Ms N’s reaction is common among patients with a new diagnosis of bipolar disorder. In my experience, there are five common reactions from such patients, and here are some suggestions for how to respond constructively.
1) “If I’m bipolar, I must be really crazy, right?” I typically respond by reassuring my patients that bipolar disorder is more common than they realize, affect-ing about 1% of people in its most severe form, but up to 7% or 8% if you consider the admittedly controversial idea of the bipolar spectrum. I find it important to define exactly what bipolar disorder is in order to demystify it: “Bipolar disorder refers to people who have periods of depression with occasional times of feeling very high, even too high.”
I share that bipolar disorder has confused generations of psychiatrists, since we used to think one had to have a classic manic episode to be diagnosed. We have learned to think more broadly about all mood disorders as occurring on some kind of spectrum and to focus on which treatment might work most precisely for any given individual.
Educating patients can help them to view their pain as symptoms rather than as character traits. For example, Ms. N had come to view her hopelessness and morbid outlook as core parts of herself; viewing them as symptoms was a relief.
2) “If you prescribe me something like lithium or “mood stabilizers,” that must mean that I will have mental illness for the rest of my life and will end up in a mental institution, right?” I explain that lithium is simply an element on the periodic table—and is therefore about as natural a treatment strategy as exists. I counteract the “life sentence of mental illness” fear by explaining how well many of my patients respond to mood stabilizers: “In my experience, most patients find that their moods actually become stable for the first time in their lives; imagine what you might be able to talk about with your spouse if you had a stable mood!”
Furthermore, I try to showcase how some aspects of their disorder can be reframed as individual strengths, eg, “There may be times when putting your artistic creativity to use might keep you out of a mental institution or prevent you from committing suicide.”
3) “How will I ever get married or be able to tell my boyfriend (or girlfriend) about this?” The fear of rejection by a potential partner is common among bipolar patients. It is hard enough for mentally healthy people to feel they are loveable—adding a psychiatric diagnosis can create a perfect storm of lowered self esteem and sensitivity to rejection.
My tactic is to explore how the intermittent gifts of bipolar sensitivity (eg, creativity, high energy, bright outlook) may have drawn his or her partner to the relationship to begin with. And I point out that in my experience the much feared conversation about one’s illness goes surprisingly well. Finally, I always offer to bring the family into a session to answer any questions they might have.
4) “Will this diagnosis take away my career?” I’ll often respond unequivocally with, “Absolutely not!” In fact, in my experience, once my patient’s mood is more predictably stable, he or she can show up for work more regularly, harness creativity into tangible results, and treat coworkers with more respect thanks to fewer impulsive outbursts.
For my patients in jobs with unusual hours—and therefore disrupted sleep patterns, I sometimes have a formal conversation with the HR department, since good sleep hygiene is so critical for recovery from bipolar disorder.
Attending a local mood disorder support group and/or reading memoirs of gifted citizens who have used their illness productively can teach newcomers that many professionals function successfully even with bipolar illness.
5) “How do you know for sure that I have bipolar disorder—is there a test to prove it?” I often level with my patients by saying something like this: “I don’t know for sure that you have bipolar disorder, because frankly, it’s a very tricky diagnosis to make. Often, the only way I can be sure if a patient has bipolar disorder is to see them several times over a period of months or years. What I do know is that you have been suffering for a long time, and that your many treatments have been only partially successful. I know that we cannot fail in our work because every step of our process will help us both to understand you. Why don’t we focus on what might be useful to feel better. There is plenty of time to worry about ‘diagnosis’ later.”