What Bipolar Disorder Looks Like- to You, to the Doctors, and to Everyone Else T hough bipolar disorder is very difficult to diagnose, the "textbook" descriptions of it make it sound like it shouldn't be so hard. After all, what could be more dramatic than shifting between extraordinarily manic behavior, feeling on top of the world and supercharged with energy, to feeling de- pressed, withdrawn, and suicidal? Consider a surprising fact: On average, there is an eight-year lag between a first episode of depression or manic symptoms and the first time the disorder is diagnosed and treated (Goodwin & Jamison, 1990; Lewis, 2000). Why should it take so long for a person with the disorder to come to the attention of the mental health profession? In part, the answer is because the behaviors that we summarize with the term bipolar disorder can look quite different, de- pending on your perspective. But even when people agree on how a person's behavior deviates from normal, they can have very different beliefs about what causes the person to be this way. Consider Lauren, who has bipolar disorder: Lauren, a 28-year-old mother of three, describes herself as an "exercise junkie." In the past three weeks, a typical day went like this: Once she got the kids off to school, she rushed to the gym, where she worked out on an exercise bicycle for up to two hours. Then, she grabbed a quick yogurt and went hiking for most of the afternoon. She would pick up her kids from school, make dinner for them, and spend the majority of the evening14 THE DIAGNOSIS AND COURSE OF IlPOlAR DISORDER on the stairmaster. But she did not consult her psychiatrist until, by the end of the second week, she had become exhausted and unable to func- tion. At this point she left the children with their grandparents and spent several days sleeping. She admitted to having had several cycles like these. Now consider how Lauren, her mother, and her doctor describe her behavior. Lauren summarizes her problems as the result of being overcommit- ted. "It's incredibly difficult to take care of three kids, maintain a household, and try to stay healthy," she argues. "My ex-husband is of very little help, and I don't have many friends who can help out. Sometimes I push myself too hard, but I always bounce back." Her mother feels that she is "irresponsible and self-centered," would "rather be exercising than taking care of her kids," and questions whether her children are getting enough guidance and struc- ture. Lauren's doctor has diagnosed her as having bipolar I1 disorder. Who is right? Lauren thinks her behavior is a function of her environ- ment. Her mother describes the same behaviors as driven by her personality attributes. Her psychiatrist thinks she has a biologically based mood disorder. These different perspectives pose a problem for Lauren, because they lead to very different remedies for the situation. Lauren feels that others need to be more supportive. Her mother thinks Lauren needs to become more responsi- ble. Her doctor thinks Lauren needs to take a mood stabilizing medication. Almost every patient I have worked with describes his or her behavior dif- ferently from the way a doctor or family member would. Consider Brent, who has been having trouble holding jobs. He says he is depressed but feels most of it is due to being unable to deal with his hypercritical boss. As a result, he thinks he needs to switch jobs and find a more permissive work environment. His wife, Alice, thinks he is manic and irritable, not depressed, and that he needs long-term psychotherapy to deal with his problems with male authority figures. She also thinks he drinks too much and needs to attend Alcoholics Anonymous meetings. Brent's doctor thinks he is in a postmanic depressive phase and would benefit from a combination of medication and couples ther- apy. Psychiatrists and psychologists usually think of bipolar disorder as a set of symptoms, which must be present in clusters (that is, more than one at a time) and last for a certain length of time, usually in "episodes" that have a be- ginning phase, a phase in which symptoms are at their worst, and a recovery phase. The traditional approach to psychiatric diagnosis described in Chapter 3 follows this line of reasoning. In contrast, people with the illness often pre- fer to think of bipolar disorder as a series of life experiences, with the actual symptoms being of secondary importance to the factors that provoked them. Family members or significant others may have a different perspective alto-What Bipolar Disorder Look, Like IS gether, perhaps one that emphasizes the patient's personality or that views the deviant behavior in historical perspective (for example, "She's always been moody"). Although often quite different, there is a degree of validity to all three points of view. In this chapter you'll gain a sense of the different perspectives people take in understanding bipolar mood swings and how these different perspectives can lead to very different feelings about which treatments should be under- taken. These perspectives include the personal standpoint, as described by pa- tients who have the disorder; the observers' viewpoint, which usually means parents, spouses, or close friends; and the doctor's viewpoint. Questions to pose to yourself when reading this chapter are: How do I experience swings in my mood? Are they similar to the ways others with bipolar disorder experience them? How do I understand my own behavior? How is my understanding different from the way others perceive me? How do I see myself differently from the way my doctor sees me? What kinds of problems arise from these differences in perceptions? Understanding these varying perspectives will be of use to you, whether you are on your first episode or have had many episodes, in that you will gain some clarity on how your own experiences may differ from those of people without bipolar disorder. You may also come to see why others in your family or worklsocial environment think you need treatment, even if you don't agree with them. Nuts and Bolts: What Is Bipolar Disorder? Let's begin by defining the syndrome of bipolar disorder. Its key characteristic is extreme mood swings, from manic highs to severe depressions. It is called a mood disorder because it profoundly affects a person's experiences of emotion and "affect" (the way he