We are bipolar disorder experts & scientists! In honour of World Bipolar Day, ask us anything!

Having been very serious with someone with bipolar disorder, but ultimately seeing our relationship implode in spectacular fashion, what tips would you give to someone dating someone with bipolar disorder that they genuinely care about and love?

Erin here. I’m really sorry to hear that your relationship didn’t make it :-(. First of all, when we talk about this, please be kind and compassionate to yourself when you try to understand your experiences. The fact that you’re here, and asking this question, tells me that you really tried to make the relationship work, and that you cared deeply for your partner.

In terms of general tips, working on good communication strategies is critical for all relationships, whether or not they’re with someone living with BD :-).It’s important to remember though that effective communication also means being able to communicate our own needs and our boundaries. To learn more about interpersonal effectiveness and good boundary setting, you could explore the principles of dialectical behaviour therapy (see for example https://dialecticalbehaviortherapy.com/interpersonal-effectiveness/). Linked to boundary-setting is assertiveness, this is a good tool for developing assertiveness skills: https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself/Assertiveness

In terms of tips for fostering relationships with people living with BD, I really like some of the blogs produced by family members and partners for BPHope (for example, https://www.bphope.com/self-care-spouse-bipolar/) and the resources provided by Bipolar Caregivers in Australia (https://bipolarcaregivers.org/ - they’ve produced a comprehensive guide: https://bipolarcaregivers.org/wp-content/uploads/2010/07/guide-for-caregivers.pdf

Natasha here - I asked my husband what his tips he would give for this question having a successful relationship with me and unsuccessful relationships with others who had bipolar in the past and he gave the following answer: Be patient and have empathy. Understand what the condition is, treatment options, etc.
From my perspective, a lot of my current relationship success is staying on top of my wellness and coming to a point where I am pretty okay in general with my mental health. I too have been in relationships in the past where my bipolar was like a third person in the relationship. I do think there’s a lot of context that might change one’s answer to this, but the thing that really complicated my romantic relationships was me struggling in general and not taking good care of myself. But when previous partners met me with compassion and unwavering support, things worked out better than they would have otherwise. It truly does take a solid foundation not only for the relationship, but for each person to be responsible for their own wellness. One thing that I personally feel gets overlooked in this scenario is that it’s not just the person who has bipolar that needs to work on themselves and their mental health – it’s everyone in that relationship.

I don't mean to be curt, and I'm sorry if this comes off as rude, but "just be patient and have empathy" can apply to any human relationship.

There are specifics to a bipolar situation which I clearly was not equipped to deal with. Granted, you can't give a one size fits all answer - but at the same time, there must be more than platitudes.

I think myself patient, but by the end I was worn out and she was angling for a fight on anything (both at fault; just life. Not blaming her).

I feel like there needs to be more than just "patience".

Edit: I appreciate your point that both parties need to work, and I'm really not blaming anything on my ex... I appreciate compassion, etc, helps. I'm sorry if my response came across dispassionately.

I was more hoping for tips on dealing with the, shall we say, extremes other than patience and sufferance. The reality is we all have a limit before it gets too much, so it's how we avoid that point. I feel there is a world that relationship worked, but it needed more than just "patience".

I hope they or someone else responds to your follow up.

I couldn't agree more.

Hello! Erin's just answered here: https://www.reddit.com/r/IAmA/comments/tsalxc/comment/i2qtoja/?utm_source=share&utm_medium=web2x&context=3

We try to get many perspectives on the most upvoted questions, but there can be a delay between as we're in many time zones and have different schedules. :-)

Thank you for your honestly. :-) We pass around highly upvoted questions like yours for input from multiple experts, from people with lived experience to people with more academic or therapeutic backgrounds. Erin has just posted another answer–we hope it's helpful.

Tera here. I am someone living with bipolar disorder that has had two different relationships since my diagnosis so I have a lot of thoughts for this question! I was dating my ex for several months before my diagnosis and he really tried to be there for me after my hospitalization, however the situation was two big for the two of us and I needed to learn how to stand on my own two feet. It is okay for either or both sides to acknowledge that being in a relationship- especially while navigating a new diagnosis- may not be the healthiest option. However, 6 years later I am celebrating a third anniversary in a very successful and stable relationship! Although a lot of what makes a strong relationship is the same regardless of a BD diagnosis, I will attempt to articulate some strategies we have used.
When we are having an argument, I try to be aware of the times when my emotions may not be proportional to the situation or when sticky thoughts are running in a loop in my mind. In these moments, I sometimes take some space and use self-regulation strategies so that I don’t say something I regret. Overall, once the situation diffuses I find it super important to debrief about what feelings/behaviors may not have been my partner’s “fault” and instead could have been the result of my lack of emotional regulation in the moment. However, this kind of self awareness can be tough! People living with BD may forget that their loved ones don’t live inside their brains and may be genuinely confused about why a response was triggering. **Overall, just because someone is living with bipolar disorder does not mean they have an excuse to treat a partner poorly, so don’t be afraid to hold each other accountable!** The love and support has to be a two-way street as both people in the relationship have needs that are equally important. Encouraging vulnerability from both ends can also help with communication and gaining a deeper understanding of each other. Hope this helps!

What is the likelihood of ADHD being mistaken for bipolar and visa versa?

Paula Nunes here: ADHD can be mistaken for bipolar disorder. ADHD can mimic the manic symptoms of bipolar disorder because symptoms such as apparent excessive energy, impulsive behavior, and poor judgment can be present in both conditions. Other symptoms that can be present in both conditions are being more talkative without realizing that others need to speak, too many thoughts at the same time or rapid speech that jumps from topic to topic, distractibility (attention is easily drawn to unimportant or irrelevant things), and increased goal-directed activities (e.g., social, sexual, or at work or school) or psychomotor agitation (purposeless non- goal-directed activity). However, in ADHD, these symptoms tend to be more stable in the lifetime - especially if untreated either by medication or by self-awareness and therapy - and in bipolar disorder these symptoms usually occur during mania. In bipolar disorder, mania is usually present in less than 10% of their life. An inflated self-esteem is more often present in mania - and not in other mood states in people living with BD.

Or having both?

Paula Nunes here: both conditions can be present in the same person. Actually, they more often co-occur; it is more common for a person living with bipolar disorder to have ADHD than someone who does not have bipolar disorder.

Hello everyone, thanks so much for doing this. I was dx’d BP1 about 5 years ago and I have tried many meds and a few therapies over the years. I’m still working through the trauma of the fallout from the manic episode that lead to my diagnosis. I’ve been in a mostly depressive state since then.

I am terrified to “get back out there” and live my life again, mostly from fear of triggering another episode. I know most of my triggers but I’m still finding it difficult to really live with this diagnosis even though I’ve made many positive and healthy changes.

I am so painfully aware of my moods now, that any positivity and joy makes me cringe. Sounds weird, but those with BP would understand.

My question is: How do you process the shame that stems from the behaviours that inevitably spiral out of control in an episode? I can tell myself over and over again that I was not in control, but deep down I don’t really believe that. Therapy has helped a bit, but I am still stuck.

I want to thrive again, and not be stuck in survival mode forever.

Thanks reading this and thanks again for your time.

Natasha here – Wow I relate to this so much. The shame is real and it is hard trying to process the things we did when we were manic or otherwise unwell. I too for a long time lived in fear of another mood episode and I felt like I wasn’t really able to trust myself with, like, anything at all. I feel like I could talk about this subject for a long time as I think there are many pieces to this puzzle, but this is essentially my short story: For a long while after my diagnosis, my identity was sort of wrapped up entirely in the reality of having bipolar. It’s hard not to see everything from that lens; I truly felt bipolar and had a hard time seeing myself as anything else. Eventually I started taking little steps out of my comfort zone – the big one for me was working full-time, but it started as small successes like re-engaging a hobby or reading a book unrelated to mental health. Essentially it was recognizing I am more than my diagnosis, and even though it’s a large part of me, it hasn’t always defined me and it won’t always define me. Being at peace with the reality that relapse is possible helped me get out of survival mode as well, but with the caveat that I knew I had professional support and I was (and still am) seeing a counsellor (aka my amazing psychiatrist) to address these very issues.

We have this narrative in recovery of “have hope” and “it’ll be okay some day” without having concrete steps of how to get there. I’m certain there are other ways to answer this question, but the shift into thriving mode was essentially finding new passions in life and taking small and safe steps to create a life I wanted to live. It might help to ask yourself, “What does thriving look like for me?” Break it down into small, easily accomplishable steps and celebrate everything no matter how small. The shame will resolve itself more or less through the process and with support from professionals and loved ones. It is a difficult process, and I did have further mood episodes – but each one got easier than the one before. And yes, there’s more shame that sometimes feels like your own personal Everest to climb. But you can absolutely go from surviving to thriving. It’s a process with many steps and it took me years, but I truly do feel like I am thriving with my bipolar in tow now.

Raymond here. Having experienced a one and only very severe manic episode approximately 24 years ago, I vividly recall how long it took me to regain a wee-bit of my self-esteem and self-confidence to the point where, after a few months of recharging my emotional batteries, I risked doing volunteer work in the laundry room of a Homeless Men’s Shelter and a group of elderly people suffering from dementia. With time, I became more self-confident and successfully applied for a front-line position with the homeless. Gradually, I rediscovered my “old dynamic-social self” back and have continued to thrive thanks to the support I received from my medication, professionals, families, friends and strangers alike. Never forget that you may have a disease but you are not the disease. I wholeheartedly support Natasha’s previous comments.

I'm a black man diagnosed bipolar, and have the assumption that my father also had bipolar disorder. I can only assume because being from a low income, minority household access to mental health services is often lacking.

I guess my question is, is there anything your team is doing to make mental health services more accessible to people like me? If so, in what ways can your everyday person provide support?

Also, for those on your team who also have bipolar disorder, how do you deal with the stigma? I tend to keep my cards close to my chest and not let anyone know, then I'll have a hypomanic episode and need to tell EVERYONE. That then makes me really embarrassed and upset.

Thanks, I appreciate everything y'all do. If it wasn't for my mental health team I wouldn't be here today.

Rosemary here. I am a Chinese woman that lives with bipolar disorder. At CREST, we are working on digital tools to increase accessibility for people who live with bipolar disorder. One example is our Quality of Life tool ,to help with self-monitering. Also in terms of your questions about how to deal with stigma, I think there are many different ways, depending on what is best for an individual to cope and support themselves. And I also want to acknowledge that whether or not you choose to disclose about your bipolar, it is a completely personal choice. I speak openly about it because I am 25 years old and have already experienced two friends who live with mental illnesses, pass away. I am an advocate for more equitable mental healthcare, as I feel that healthcare professionals often still discriminate against marginalized and underrepresented people/communities, when they provide care. I feel strongly about speaking out for those who can’t, and I am also at a place in my life where it doesn’t compromise my safety in a huge way. I also feel that I can take the stigma and discrimination that I may face for speaking out, because I have done significant work to build boundaries against having that impact me too strongly. This is all to say that if you DON’T feel that it is safe to disclose this, if you feel you will have a target on your back at work, or within your community -- I want to again emphasize it is a completely personal choice. You know your situation best. There is no golden badge for disclosing that you live with bipolar disorder. It is up to you, to disclose it if and when it ever feels right. I think the only thing that I will end with is that disclosing to one or two close and trustworthy humans in your life has the potential to mean that these people can learn to support you and offer you care in times of need, more effectively. Thank you for sharing your experience, and I am grateful for your mental health team as well, and glad that you are here today.

Natasha here – My hypomania is why I ended up doing public speaking about having bipolar so I can relate! I think everyone ends up finding that out about me, as now completely stable me still tells people. But I also have a different view of this because I’m white and we know folks of colour have different experiences, so I can imagine it might be a more complex conversation for you specifically. Saying it’s hard dealing with stigma and different layers of discrimination and oppression is an understatement. Really my contribution here is just to say that you have a very important voice that needs to be heard and if you are ever in a place where you feel comfortable doing that, it would benefit us all.

KERI GUELKE here. I have started opening up over the last decade about my BD diagnosis to the point that I forget who I’ve told. But it’s easier for me when I haven’t had an episode in such a long time. What’s surprising to me is how many people say ‘me too’ or know someone with BD. There are a lot of cool famous people with BD - I like to mention some of those people when I talk about it. I think that helps decrease the stigma.

Erin here. I’m so glad you asked this question. You assume right - there is a clear negative relationship between SES, race/ethnicity and access to (appropriate, inclusive and culturally safe) mental health services. Can I ask where you’re based? The Depression and Bipolar Support Alliance (DBSA) in the US is providing peer support groups, locally and nationally, specifically for Black individuals living with a mood disorder. The groups, led by a Black peer facilitator and a support specialist, also offer one-on-one support services to group members at the end of each meeting: https://www.dbsalliance.org/dbsa-outreach-to-the-black-community/#:\~:text=DBSA%20is%20also%20launching%20new,the%20end%20of%20each%20meeting.
From a research perspective, not enough attention has been paid to specifically exploring experiences of black people or communities with BD. We wrote a blog on race and BD in 2020: https://www.crestbd.ca/2020/09/10/findings-race-bipolar-disorder/ and the state of the science in this area remains poor in 2022. We’ll continue to weigh in as a group on your question over the course of our 48 hour AMA - bear with us for timing of responses please, as many of our panelists are joining from other countries in different timezones, or are joining at the end of their workdays, thank you!

Mollie here. I echo Erin’s response above–the field of psychiatry has been pathetically slow in responding to the mental health needs of minority communities. When our research group at UCSF partnered with CREST.BD in conducting studies exploring the lived experiences of people with BD, we talked a lot about the ways medical researchers often unknowingly exclude BIPOC communities, as well as the (very understandable) lack of trust many people from BIPOC communities have in the medical research system. All of this results in low representation of BIPOC and other minority groups in mental healthcare and clinical research. To address this issue, our team took steps (e.g., providing education and outreach, making our study postings more colorful and less full of medical jargon, holding flexible times for study involvement so that people working long or odd hours could participate), to *hopefully* make our study feel more welcoming and approachable. Obviously a lot more work needs to be done in this area. I believe most of the responsibility falls on mental health teams to modify their approaches to better serve diverse groups. However, individuals can also provide support by sharing opinions and stories (to whatever degree feels comfortable) to help empower other people to seek mental healthcare when they need it. Additionally, being vocal with mental health providers when their services are not effectively reaching minority communities can help urge healthcare systems to evolve towards more ethical and inclusive practices.

As someone with bipolar, my latest hurdle has been anger and rage. Does this fall under mania/ hypomania umbrella? What’s the best way to manage it? Thank you!

Sarah here. Anger and rage can be something people experience during and outside of mood episodes. You will often hear it called “irritability.” It is more often associated with hypomania and mania but can also happen during depression. When I have clients who report hurdles such as these, I recommend that they consider finding a provider who can do Dialectical Behavior Therapy (DBT) with you. DBT teaches different skills such as emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness. These can be very helpful for reducing irritability, anger, and rage. You can find group DBT therapy or individual therapists. If there are not any providers with this training in your area, then I would recommend starting with a great workbook I recommend that you can find here: https://www.amazon.com/Dialectical-Behavior-Therapy-Workbook-Disorder/dp/1572246286/ref=sr\_1\_1?crid=10FILY5DRZYTF&keywords=DBT+for+bipolar+disorder&qid=1648662171&sprefix=dbt+for+bipolar+disorde%2Caps%2C201&sr=8-1

Louise here. As someone living with bipolar 1 disorder for 30 years, my extreme rages have only been in the manic state to the point where I have been physically violent towards others. I took an anger management course which helped. The best way for me to manage the rages is to avoid mania at all costs. I do this by calling my psychiatrist immediately at the very first stirrings of hypomania because it can progress to mania in my case. It is much easier to contain hypomania in the early stages than it is to reverse mania once it is in full swing. This has proven to be very effective as I have not had a rage in 25 years. I also find it is important to practice self-compassion after a rage to deal with the shame you may be experiencing.

Lithium is the "golden standard" for bipolar disorder (BD). It is a neuroprotective medication and probably the only one that can prevent suicidal ideation and the common occurrence of Alzheimer's disease. Yet, I hear more and more that it is not effective for everyone and I see it less and less recommended.

My question is: What's the role and understanding of lithium nowadays? Bonus: As a bipolar patient without good medication yet, should I ask that we consider lithium for my treatment plan or its alternatives are better?

Thank you very much.

Andrea HERE - I understand that this question may be best for a medical professional but as someone who has been on lithium for 17 years, I feel that I can offer some insight. Lithium is an effective medication for many people but obviously not for all. However, I have seen more successes from lithium than failures in my relationships with others who treat their bipolar with it. I was never able to reach stability with other meds, but my world of stability opened up with lithium and I am grateful it worked for me. I cannot recommend that you try lithium but to talk to your doctor if it would be an ‘option’ for you. We are all unique and there are many things your doctor will assess about your physical health and mental health when considering lithium. I take lithium in a smaller amount in conjunction with 4 other meds that create a cocktail. It took 11 years to find the most effective mixture for me, so I always tell people to be patient with their med regime. IT TAKES TIME! I can never stress this enough. In closing, lithium is cheap for pharma companies and newer options are more expensive. They don’t make money from it. This is a fact. However, this does not mean that lithium is obsolete because it is often the most effective for someone, even if it is an older drug. Again, it depends on the person and their doctor’s advice of their treatment.

Trisha (psychiatrist) HERE - Lithium has robust evidence showing that it can be effective for treating both depressive and manic episodes in BD, as well as preventing the recurrence of these episodes. Even though it’s one of the oldest mood stabilizers we have, there’s no doubt that it can be very helpful for a lot of people, as Andrea described. Like every medication though, not everyone will find it equally useful. There is some evidence that people who have predominantly ‘mixed’ symptoms (so symptoms of depression and mania occuring at the same time) or have rapid cycling (more than 4 mood episodes in a year) may not benefit as much from lithium as they may some other mood stabilizers such as valproic acid. The evidence is far from definitive, but it SUGGESTS that those who may do the best with lithium have less frequent episodes, and do not show mixed or irritable symptoms in mania.
There are also some monitoring requirements that can make patients and clinicians more hesitant to try lithium - you will get your blood drawn more frequently when you start to determine your serum levels, and then once at a steady state approximately twice per year. Individuals taking lithium also to need to make sure that they are remaining hydrated and need to stay from certain blood pressure and pain medications to make sure that they don’t develop a toxic level of lithium, which is possibly life threatening. Lithium can also have some side effects, such as increased urination and thirst, weight gain, tremor and fatigue. That being said, every medication comes with side effects, and many individuals can tolerate lithium well.
So I guess in summary, lithium can be a valuable tool for managing mood symptoms in BD. Some of the issues around monitoring and side effects - and as Andrea said, it being older and for various reasons therefore not as enticing to study - have limited it use lately. However, it should always be considered as an option.

Hello, bipolar here. How do you differentiate between type 1 or type 2 in a patient? Can someone have symptoms who don't fit those two?

Sarah here. Thank you for your question. There are a couple of differences between type 1 and type 2. People who get diagnosed with type 1 have a history of a manic episode. In type 2 people have a history of hypomanic and depressive episodes. The thing that is different between mania and hypomania is the intensity of the symptoms. In mania, symptoms tend to result in significant impairment to one’s relationships, work functioning, or difficulties in activities of daily living. In hypomania, people tend to experience similar symptoms but to a lesser degree - they don’t tend to cause significant impairment but are a significant chance from one’s self. Please know that this does not mean that type 2 is not as “severe” as type 1 - often depression that comes along with type 2 can be severe and the lived experience of type 2 is not just a “mild form” of type 1. To answer your second question, yes, people do not always fit nicely into these categories. A lot of research, including my own, suggests that bipolar disorders fall on a spectrum (not just type I and type II). Note that we do have a diagnosis, other bipolar spectrum disorder, that can capture those who have symptoms that sound like bipolar disorder but do not neatly fit into these categories.

What are the similarities and differences between Borderline Personality Disorder and Bipolar Disorder?

Hi, Emma here. I want to start my answer to this question by acknowledging that although I’m using the term “borderline personality disorder”, I recognise that for many people this label can feel stigmatizing and inaccurate (after all, it’s essentially implying that personality, a core part of who we are as people, is broken or disordered). But, in the interests of making my reply to this question easily searchable for someone who is looking for information on this diagnostic label, and to make it clear that I’m referring to research which has specifically looked at the constellation of difficulties we call ‘BPD’, I’m going to use that acronym in my response.

The diagnostic criteria for bipolar disorder and BPD do share some similarities - they both involve the experience of irritable moods, impulsivity, emotional lability (mood swings), and sometimes suicide or self-harm can result. As a psychologist, it’s really important for me to get the diagnosis right, so I can use the treatment strategies supported by research for that condition. For example, we know that supporting people to have stable daily rhythms helps protect against mood episodes for a person with bipolar disorder, while somebody experiencing the kind of extreme moods associated with BPD may be best helped by dialectical behaviour therapy, which teaches emotion regulation and interpersonal skills.

The main things I look for to tell apart bipolar disorder and BPD is the duration and frequency of mood shifts. In bipolar disorder, these tend to be more prolonged -we’re talking days or weeks - and separated by periods of relatively euthymic mood, whereas people with BPD tend to experience more frequent, brief, intense emotional shifts over the course of a single day. The kinds of life stressors that trigger these mood changes are also important - people with bipolar disorder commonly experience mood episodes following sleep disruption, and sometimes seasonal changes, whereas people with BPD are often quite specifically triggered by interpersonal stress. Concerns about identity are common in both conditions: people with BPD often report having an unstable sense of self (feeling like “I don’t know who I am”). Similar concerns are raised by people with bipolar disorder, but this is often described in terms of the difficulty maintaining a stable sense of self across the different mood states. A decreased need for sleep (not insomnia) when manic/hypomanic is also fairly unique to bipolar disorder. Finally, we can get relevant diagnostic information from a person’s family history: a first degree relative with bipolar disorder is a strong indicator of bipolar disorder. Even though increasing awareness is being paid to the role of childhood trauma in BPD, this is common in the histories of both people with bipolar disorder and BPD, so that may not help us differentiate the two.

I will say that the clarity around these diagnoses is not helped by the fact that bipolar disorder is sometimes abbreviated as BPD too!

Where and how to draw the line? At times, their reactions/behaviors can feel/are very much abusive. I'm struggling very much with the balance of being understanding of an irritability episode vs letting myself be disrespected like that.

When discussing this with our pych team, at times, feels like almost everything this person does can be passed because of BD. I feel like I'm always in second place, I'm building tons of resentment and I feel like I'm not allowed to have feelings.

Andrea HERE - I have heard this a lot from loved ones who are attempting to support a person with bipolar. I have been diagnosed for 17 years and I want to stress how important it is to have boundaries with all people and this includes someone in your life who has bipolar disorder. Nobody deserves to be disrespected and we have to be clear with all people in our lives about what is acceptable and tolerable. Bipolar is not a ticket out from being responsible for one’s actions. I do understand that it can be a slippery slope. Check out my blog here from BP Hope that has some insight on this topics: https://www.bphope.com/blog/are-you-responsible-for-your-actions-when-you-have-bipolar-disorder/

Bipolar 1 runs in my family. Is there any known connection with BD and adverse reactions to THC?

I once tried a THC edible and hallucinated while puking my guts out all night. For reference, I do not know the mg of said edible.

Erin here. Questions about BD and THC came up a lot in our AMA last year too - we created a blog summarizing the responses from our panel, find it here! https://www.crestbd.ca/2020/04/20/bipolar-cannabis/ As part of our response, we recommended reading the Canada’s Lower Risk Cannabis Use Guidelines, which can be found here: canada.ca/content/dam/phac-aspc/documents/services/publications/drugs-health-products/cannabis-10-ways-reduce-risks/lrcug-eng.pdf

Victoria here - Oooh boy I can relate. I too tried and smoked cannabis years ago. This was after I had been diagnosed with rapid cycling bipolar disorder 1 with psychotic features and already had a couple psychotic episodes but had been stable for quite some time. The result was not good. I went into a psychosis where I was quite delusional and had minor hallucinations. I don’t know if this is the case for everyone with BD, but it is for me. From that experience I stay away from any THC products or smoking cannabis.

How often is Bipolar disorder misdiagnosed as ADHD? Is it possible to have manic episodes that are caused by ADHD?

Sarah here. There was a great response from my colleagues earlier about the differences between ADHD and Bipolar and why they can easily be misdiagnosed especially when an assessment is a one time snapshot of someone. To summarize, there are some key differences that can help distinguish between the two:

1. typically the onset of ADHD symptoms are in early childhood (~ age 7 on average) whereas with bipolar disorder the age of onset tends to be later in adolescents/young adulthood,
2. ADHD symptoms tend to be chronic whereas in bipolar disorder they tend to episodic or cyclical, and
3. while we do see high rates of depression in ADHD, mood symptoms are much more prominent in bipolar disorder.

Studies to date suggest that approximately 20% of adults with ADHD also have bipolar disorder, while only 10-20% of adults with bipolar disorder have ADHD (Brus, Solanto, & Goldberg, 2014). So, there is some evidence that they can co-occur, but whether that is due to diagnostic problems because of symptom overlap, is up for debate. I can say that this is a topic we are studying further! Lastly, I’ll add that while I have not seen evidence that ADHD itself can cause bipolar disorder, stimulant medications prescribed to treat ADHD can, in some cases, induce mania. So, if you are recently diagnosed with ADHD and considering stimulants, it is important to tell your providers that you live with bipolar disorder as well so they can monitor for stimulant induced mania. There are treatments for ADHD that are less likely to reduce the risk of mood destabilization so you can talk to your provider about these options!

Hello,

Thank you for doing this ama.
I'm very interested in how the manic state takes place in the brain. Is it possible to summarize or describe what is happening biochemically in the brain during a manic episode?

Thanks for any info.

Raymond here: From a non-scientific but practical point of view, it’s best described as experiencing a hot-flash in the brain. It’s a whirlwind and thus your thoughts and behaviors also follow suit. It’s a wild circus where the main wild controlling beast has to be controlled asap. Otherwise, severe damage will occur.

Sarah here. There is some research that suggests that this “hot-flash” reflects the way that certain neurons and cells in the brain communicate. In simplest terms, neurons “light up” more in reaction to being perturbed in individuals with bipolar mania compared to those without bipolar mania. The story is very complicated, and likely not “the answer”. Also important to note that these findings are in cells grown in the lab from samples taken from individuals with bipolar disorder. But, there are certainly groups following up studying the ways in which the neurons and cells in the brain fire, communicate, and are structured and this may be one piece of the puzzle when understanding what is happening biochemically in the brain. Here is an article if you are interested in reading more: https://www.nature.com/articles/tp201412. In addition, one of my collaborators reported that there were differences in energy metabolism in the brain of individuals with first-episode bipolar disorder. This makes sense when we think about mania and the changes in energy felt in the body - this may be happening in the brain too! Here is this article: https://pubmed.ncbi.nlm.nih.gov/28527566/

Is Bipolar often a co-morbidity of alcoholism? How often is Bipolar disorder misdiagnosed? (BPD, etc)

Erin here. In answer to your second question - is bipolar disorder (BD) often misdiagnosed - the answer is yes, fairly often. A few studies have looked at how long on average it takes for people to get the ‘right’ diagnosis of BD, and the findings tell us that it can take around a decade. Often, people are diagnosed with depression first, and then BD later on in their life. Partly this because diagnosing the condition can be complex, and can only occur after a person has experienced a clear episode of hypomania or mania. People don’t always seek treatment when they’re experiencing hypomania, which can at first seem like a welcome relief from depression. Another issue is that we need to support better training for primary care providers to detect and diagnose BD. Learning more about the common signs and symptoms of BD can help you to determine whether you might be on the spectrum. And it’s a good idea, if you think you are, to start measuring your mood using a mood diary or an app on a daily basis. Having this “data” in-hand when you consult with a healthcare provider can be a powerful tool.

edit to add: We'll have another expert weigh in on your first question later. :-)

Sarah here. I am responding to the first part of your question. A large portion of individuals living with bipolar disorder also have difficulties with alcohol use. For some, they may have problems with alcohol use before the onset of their first manic episode, for others, it develops after the onset. We don’t have clear evidence that alcohol use itself can cause bipolar disorder. However, we do know that when individuals with bipolar disorder have alcohol use problems, their symptoms of bipolar disorder tend to be less under control and treatments may not work as well.

Tom here. I worked with Bipolar UK to do a survey about this and unfortunately 60% said they had been mis-diagnosed as unipolar depression. The highs are often missed. There was on average nearly 14 years between first depression and bipolar diagnosis, and nearly 10 years from first hypomanic/manic episode to BIpolar diagnosis. https://www.bipolaruk.org/Handlers/Download.ashx?IDMF=afa4ab1e-eb99-4a6e-8af1-79f4472d25e5.

Erin here. To your first question, people with bipolar disorder are more likely than those without the condition to drink too much alcohol. One systematic review found alcohol use disorder affects more than one in three people with BD, affecting more than one in five women and two in five men. It’s important to know too that substance use and mood symptoms are closely connected: substance use can cause mood symptoms and mood symptoms can cause substance use. Many communities have programs for those dealing with substance use problems, including alcohol counselors, detoxification facilities, residential treatment centers and support groups like AA. There are also some great apps available to help you connect with other people who are also working on reducing their alcohol use, like https://iamsober.com

The physicians assistant who manages my medication insists that manic-depressive cycles are exclusive to having bipolar disorder.

My therapist says that is not true, and my complex PTSD can cause me to have manic-depressive cycles without me having bipolar disorder.

Who is right?

Hi, Emma here - I’m sorry you are having that experience, it must be frustrating to not have a clear answer about what is potentially going on for you (and also to feel like you are in the middle of two opposing opinions!)
First off, I want to acknowledge some of the limitations of our diagnostic system when it comes to mental health. Unlike some medical conditions like Huntington’s disease, where we can confidently diagnose its presence or absence based on whether or not a single specific gene abnormality is present, we have no such test for bipolar disorder. In fact, the entity that we call bipolar disorder is based on decades of observations about symptoms that tend to co-occur, but our understanding of that and other conditions is constantly evolving based on new research (as reflected by the fact that we are now up to the fifth edition of the diagnostic and statistical manual). Diagnoses are pragmatic tools to help clinicians understand what is likely to occur for a given individual reporting a given set of symptoms, and which treatments are likely to be most effective.
I also want to acknowledge that the way that we understand reactions to interpersonal trauma are evolving, but as of yet we don’t have an agreed upon set of symptoms which make up a diagnosis of cPTSD that is included in the DSM. Although the diagnosis was included in the ICD-11, this only came into play Jan 1 2022, and researchers are still in the early stages of investigating which symptoms reliably cluster together, and how they differ from other disorders (including bipolar disorder). So I’m going to give the next part of my answer cautiously, given that there is limited research so far. I’m also going to lean on what we know about how manic/depressive episodes differ from emotion dysregulation (a proposed symptom of cPTSD) based on research on the constellation of symptoms that is currently called “borderline personality disorder” (the labeling of which has its own controversies, but I’m going to use it here to help people who might have been given that diagnosis find this answer).
As a psychologist, what I would be looking for to differentiate problems with emotion dysregulation from bipolar disorder is whether these changes in mood are short lived (they tend to be of longer duration in bipolar disorder - we’re talking days or weeks rather than hours), what triggered them (e.g., sleep loss is a very common trigger for people with bipolar disorder), and whether or not the individual has periods of stable, euthymic mood in between manic or depressive episodes (whereas someone with emotion regulation difficulties might experience constant, disproportionate reactions to life events). Importantly, the way these difficulties are treated would be different, so if your healthcare providers aren’t in agreement, it’s okay to ask for a third or even fourth opinion.

Is the gut biome a subject of research yet in regards to bipolar disorder?

If not, should it be?

Dr Tamsyn Van Rheenen here: Great question. The gut microbiome is actually the topic of increased research attention lately. A recent review published in Bipolar Disorders looked at a range of studies that had been done on the topic and showed that low alpha diversity (number and distribution) in two types of bacteria, Faecalibacterium and Bacteroides, may be associated with bipolar disorder. You can find the link to the article here: https://onlinelibrary.wiley.com/doi/abs/10.1111/bdi.13049. Unfortunately it's behind a paywall, but if you’d like a copy you can email me at [email protected] and I can send it to you.

Dr. Gorman here: Thank you for raising this question, and I will only comment on my experience. Years ago, I participated in research looking into whether certain foods fed to animals for behavioral disturbances could be effective for people with bipolar disorder. Subsequently, I worked with a psychiatrist named Dr. Leslie Wicholas who analyzed patient’s diets and the role it could be playing in their mood disorder. Now, you can look up and find nutritional psychiatrists. This is such an important factor in patient’s mood disorders that were once refractory, and are now having quality in their lives, I’ll leave you with this one link: https://www.bonappetit.com/story/nutritional-psychiatry

Is it possibly to safely trigger an extended period of hypomania?

Victoria here - I live with bipolar disorder. I talked to a psychiatrist who I worked with about this. He said if I noticed I was in a hypomanic phase to be careful because it is a very slippery slope. It can quickly flip into full blown mania without notice. So I never intentionally tried to trigger one. The potential consequences of intentionally creating one far outweighed any benefits. Hypomania easily can pop into mania where it is likely I will do a lot of damaging behavior and potential do things I wish i hadn’t and even need to go into the hospital. A question you might ask yourself is why would you like to be hypomanic? For me if I am missing it, it usually means I don’t have that vitality in my life, that I’m missing some joy or simply not having much fun or engaging in enough creativity or perhaps feeling disconnected from my spirituality. When I look at it that way I can do things that feel satisfying and fulfill those needs. So I might write for pleasure, do some kind of craft like make a card, go near the ocean to feel that expansiveness, practice some Chi Kung or meditate. I’d be interested in hearing what one of our health professionals has to say or recommend. Hope this helps!

Tom here. I completely understand the urge to ‘go with’ hypomania because it can feel great initially; you might feel creative and productive etc. This can be especially ‘tempting’ if you have been low for a while. But unfortunately it's playing with fire, it's a risk. It is likely that it will increase further and further and be harder to wind things down the higher you get. It starts off feeling nice, but can feel unpleasant or start getting you into trouble, and at that point it's hard to ‘turn it off’. It's like being on a skateboard at the top of a really steep hill: It’s great fun at first but if you don't get off early it will get faster and faster until you feel out of control and fall off and get hurt.

Could you explain some of the life expectancy reductions associated with the disorder? Is the lower number due to age averages including suicides or does being on the various medications affect it?

Hi, Emma here - challenging question to talk about, for sure. Sadly, there is evidence to suggest that life expectancy is 10-12 years lower for people with bipolar disorder as compared to the general population. While some of that can be attributed to deaths by suicide or accidents, a large portion is due to physical health comorbidities. People with bipolar disorder are at higher risk of cardiovascular, endocrine (related to hormones, e.g., diabetes), and metabolic diseases. The reasons for this are complex and multifaceted - there may be some shared biological mechanisms between bipolar disorder and these medical conditions; and some factors associated with bipolar disorder (e.g., substance use, obesity) may be a risk factor for developing these health conditions. Whether obesity in bipolar disorder is due to the condition itself, side effects of medication, or lifestyle factors (or even a combination of these factors) likely varies according to the individual. I will note that a particular problem for people with bipolar disorder is getting adequate care for their physical health - unfortunately, people with serious mental health issues may have their physical health problems overlooked by doctors. That’s definitely something we need to get better at systematically asking about and screening for. The good news is that a large-scale UK study found decreasing rates of all-cause mortality since 2000 for people with serious mental illness (including bipolar disorder). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5579328/

Hi, this is my first time here, so I'm not quite sure of the rules. :). I have a number of questions but I'll start with this one: 1) Do antidepressants lose their effectiveness in menopausal women? I just went through "the change" and have BP2. I've been in an extremely long depression and have yet to find relief from anhedonia and amotivation. Thanks in advance.

Victoria here - Oh I hear you. I’m so sorry you’ve been going through a long depression. It’s incredibly hard to go through. It feels like it will never end. But that’s the lie depression tells you. It WILL end. Trust me. I have bipolar disorder as well. I’ve gone through so many depressions but they always lift. In terms of your question. I can relate. I’m 55 and went through menopause. I noticed my mood and the effectiveness of my meds changed. My anxiety skyrocketed too. My usual coping tools weren’t working like they did in the past. It was very, VERY scary. So I worked with my psychiatrist to find a either new amounts of my standard meds or try new ones. What ended up happening was that we did a bit of both. I increased one med, added a new one and added some supplements (like Omega-3 Fish oil with Vit D, magnesium citrate, upped my vit D). It took more time that I’d like to admit for me to come back to my solid baseline and out of the depression and anxiety. But I did. You can too. It’s important not to give up hope and work with a good health provider. If you’re not happy with what they are doing, keep advocating for yourself or get a buddy to help you advocate with you. It’s hard if you’re depressed to say what you need sometimes. I found depression whispered the lie, that it wasn’t worth the effort and that anything I did wouldn’t help anyway. But that’s depression talking, it’s not the truth. Tara Brach has a great saying: It’s real, but not true. That is depression is real, feels real, but what it tells you isn’t true. I wish you all the best.

For a major figure like Kanye to be diagnosed and dealing with the Bi-Polar disorder on a public stage and is consistently being scrutinized (warranted and unwarranted in my opinion), how can that add extra challenges to one’s ability to get their experience under control?

Georgina here, I have been pondering this point myself. Being in the public eye has its advantages and challenges. Media attention and scrutiny (including on social media platforms) can create additional stress and pressures on individuals and their loved ones. This can be magnified after a particular event/’scandals’. There is a lot of evidence that for some people living with bipolar disorder, stress can impact on their symptoms both depressive and (hypo)manic. A good support system in friends, family and one’s team are likely to help during these times

My aunt is in her late 40s and was recently diagosed with bipolar. As far as we know she only first had symptoms about 2 or 3 years ago. I also am bipolar but my symptoms first started as a teenager and I got diagnosed in my early 20s. So my questions are:
a. is her prognosis similar to mine or diffferent since her symptoms came a lot later in life?
b. will the same advice my doctors gave me work for her?

Paula Nunes here. Usually bipolar disorder starts in early adulthood, but it is still very common to start in the late 40s, especially when an important life event happens at this age. Therefore, her prognosis is similar to yours and the same advice works for her. If the symptoms start later in life it is important to rule out disorders that start in older adults such as dementias. But usually dementias and other neurodegenerative disorders start after 60 years of age or even later.

Annemiek Dols here. One would think that the age of first symptoms is important in term of clinical presentation, treatment receommendations and prognosis, but as Paula stated early and late onset BD seems to be more alike than different.

How bipolar disorder is diagnosed?

Can different doctors give different diagnosis? I ask this because I have a close family member that was diagnosed with bipolar disorder but other psychiatrist didn’t diagnose with bipolar disorder.

Is the diagnosis bases only on descriptions from the patient of how he feels or is there any tests available to diagnose like for Alzheimer’s?

Hi, Emma here. Unfortunately, there is no biological test that can tell whether or not somebody has bipolar disorder. This is complicated for a few reasons - there are lots of genes that are potentially involved in bipolar disorder, these genes are pleiotropic (meaning, involved in the expression of several different mental health disorders), and having a genetic vulnerability to bipolar disorder does not mean that you will necessarily develop it. It comes down to a particular combination of predisposing factors and life stressors.
Because of that, we rely on the information we hear from a patient and their family/friends to make a diagnosis. People may seek care at different phases of the condition, and so the information that we have available may change. We know that reliability (the consistency with which clinicians make the same diagnosis) is best when someone is acutely manic. However, depression can be confused for unipolar depressive disorder, especially if someone does not remember their manic episodes, or see them as a problem. It also depends on clinician training and familiarity with various mental health conditions: unipolar depression is much more common, so a doctor that sees someone who is depressed may miss signs of bipolar disorder. They may even confuse hypomania for a sign that someone is improving from a depressive episode. Unfortunately, we know from research that something like 60% of people with bipolar disorder are initially given the diagnosis of major depressive disorder, and it can take 5-10 years for people to receive an accurate diagnosis. That’s why events like today (world bipolar day) are so important for awareness raising!

Thank you so much. Your reply is really helpful. All this IAmA is really helpful. Thank you for organising this

So happy it's helpful. :-)

Can psycho assisted therapy with mushrooms (golden teacher) trips help bipolar depression when all medications have failed?

Mollie here: This is an excellent question, and one that the psychedelic research field is beginning to address. While there is not yet published data to demonstrate whether psilocybin therapy can be safe or effective in treating bipolar depression, at least one research group (UC San Francisco) is currently conducting a clinical trial with this population. Additionally, UC San Francisco has partnered with CREST.BD to conduct a study exploring the firsthand experiences of adults with bipolar disorder who have used “magic mushrooms.” While that data is still in the publication process, as one of the primary researchers I can tell you that psilocybin mushroom use can sometimes be safe and useful for people with bipolar depression, though it can also lead to dangerous or unhelpful outcomes when not used in intentional, supportive contexts. Our team is writing two papers on this topic that should be published in the coming months. I imagine the CREST.BD website will have some posting once they are published.

Tom here. I’m not an expert on this but I know there is more research for unipolar depression than Bipolar depression at the moment. There was a Crest BD webinar from an expert which might be worth a watch: https://www.youtube.com/watch?v=\_kdd2g4CLkM.

Is bipolar disorder hereditary?

Hi, Glorianna here. This is a good question on which quite some research has been conducted already without a conclusive answer. What we know today is that relatives of people with a bipolar disorder diagnosis have a ten times higher risk to meet criteria for bipolar disorder as well and about 60% of people who meet criteria for bipolar disorder have a first-order relative with an affective severe mental health issue (major depressive disorder or bipolar disorder). However, genetic research has to date found no genes consistently and exclusively associated with bipolar disorder, but rather a number of small genetic variations that are also associated with an increased vulnerability for severe mental health issues in general. Studies with monozygotic (identical) twins showed that not always both twins do experience bipolar disorder symptoms. This indicates that other factors beyond genes/heredity must be important for whether someone will experience bipolar disorder symptoms or not.

The current understanding in most research and Western health systems for the development and persistence of bipolar disorder symptoms is the bio-psycho-social model. Very briefly summarized, it posits that stressful life events may trigger mood episodes for people with an increased vulnerability, which may be due to genetic factors or previous adverse life events.

Rosemary here: I was diagnosed when I was 12 years old, and it surfaced during a period of time where I was being severely bullied in school. This is quite a rare age for people to receive a diagnosis but I did, due to my extreme behavioural changes in school, and my general withdrawal from life, and some other symptoms. I have no grandparents with known bipolar disorder, my sister and parents all do not live with a known mental illness. I feel hesitant at times, morally, about how I feel with an increased chance of passing down living with bipolar to my children, if I should have any. However, if this is at all related to your question, or if this is helpful or validating to hear, I do strongly believe that because I have been able to foster a full and meaningful life for myself, I know that I would be able to do my best to help my child do the same. Acknowledging that the decision to bear children is completely personal, and also the ability to bear children is also a privilege as well as a whole other thing (ie., do I feel like I could go through a pregnancy or would it affect my mood too much?)

As a person with BD, I have a hard time understanding how to recognize what a "normal" mood is. I understand the extremes of each elevated/depressed mood but have a hard time understanding what normal is vs when my mood is leaning one way or the other. This is complicated by the fact that I have assumed that being on the edge of hypomania is normal for most of my life.

Any tips on how to understand what a normal mood feels like or how to identify one?

Natasha here – Finding my normal was one of my main quests after receiving my diagnosis. I didn’t really find my answers until I was in a place where I stabilized on medication. First I had to identify what my mania/hypomania and depression looked like. In my experience, I didn’t ever really feel “normal” mood – it always felt like chaos. So I sort of had to “discover” it through a process of elimination. I figured out my warning signs for mood episodes and eventually started looking for the space in between episodes and what that looked/felt like. I did keep a journal tracking my moods and symptoms and retrospectively started to see how I was describing my moods so that I could look back and say “oh yeah, that was a pretty stable time for me.” It was hard to see it in the moment, but I was able to figure it out by looking at my history. Hope that helps.

In an individual living with bipolar disorder are there trends in the timing of mood shifts? Are trends tracked individually?

What kind of shared research is done to find commonalities between people living with bipolar disorder?

Are there early indicators/triggers that are known?

Is there a a hormonal aspect to the disorder?

Thank you for your time!

Sarah here. Thank you for your question. This is something we are actively studying in the Prechter Bipolar Program at University of Michigan. For some people (not all) there does appear to be a seasonal pattern whereby mania/hypomania is more likely in Spring and Summer months and depression more common in late fall/winter months. In order to answer some of these questions, we are following individuals with bipolar disorder over time. For one month during each season, we measure sleep, mood, light exposure, and other symptoms. That way, we can see if different symptoms emerge across the four seasons. Anecdotally (as a clinician, not with my research hat), I have had many people living with bipolar disorder tell me they experience mania at the same time every year and sometimes can even pinpoint a week of the year that they remember having symptoms. You can learn more about our efforts here! https://medicine.umich.edu/dept/prechter-program/bipolar-research/bipolar-disorder-research-projects/sleep-across-seasons-study-sass

Erin here. There’s excellent research available exploring the link between life events (as potential triggers) and mood episodes in BD. It’s worth knowing that both positive (e.g., graduation, a new job, birth of a child) and negative (e.g., a bereavement or loss) life events can precipitate mood episodes. It’s also worth knowing that people’s individual triggers are often both idiosyncratic and consistent, so it’s worth stepping up your vigilance, self-care and supports when you know you’re facing life circumstances that might be destabilizing for you.

Hello!

I was diagnosed with bipolar disorder four years ago. I'm in active treatment and compliant with my medication. I'm 28.

How quickly does neurodegenerative decline happen with this disorder? What difference does sustained treatment make? (Lithium/lamictal/risperdal/vraylar.)

Trisha here - Thank you for the great question. I will start by echoing Erin’s comment that neurodegenerative decline is most certainly not a given with BD. In fact, studies that have followed groups of individuals with BD over several years indicate that the average cognitive performance of these groups did NOT decline with time, and in fact showed some improvements (if you are interested in looking at some of these studies, see https://pubmed.ncbi.nlm.nih.gov/28585513/ and https://pubmed.ncbi.nlm.nih.gov/31840225/). Studies would also indicate that long-term treatment which minimizes the number of mood episodes will help preserve cognition, so being on sustained effective treatment will most certainly help. In addition, so will all of the things that help with general cognitive health, including healthy diet, exercise and remaining socially engaged.

Erin here. I will let our experts in neurocognition weigh in on your question fully over the course of the day, but I will start the conversation by saying that neurodegenerative decline is not a given :-). More to come, thanks for your question!

It seems like I hear about people with bipolar not believing their diagnosis and not not being medication compliant more than other mental illnesses. What is it about bipolar disorders that make people feel and behave this way? (Asking as someone who has been diagnosed with bipolar but frequently questions that diagnosis)

Erin here, you’re right, it is really common for people to be unsure about their diagnosis, especially in the early stages after first being diagnosed. And non-adherence with medications is also quite common. I think that one of the things that’s special about BD is that a lot of people with the condition have subjectively experienced periods of really highetened wellbeing/productivity. Those periods (usually during mild hypomania, not full mania) are alluring and tantalizing and can, understandably, be missed or longed for.

in your professional experience, have you ever seen someone fully recover from Bipolar 1? Recovered meaning off of medication for >1 year, functional, and without mania / psychosis / depressive symptoms?

Annemiek Dols here. Absolutely. I have a practice where I see people aged 60 and over with a diagnosis of bipolar disorder. Often they have been stable for a long time and sometimes we can reduce and eventually stop their medication, of course in close collaboration and with family involved. Moreover, I have started a study on people aged 50 and over with a diagnosis of BD that are off medication for more than 5 years. I have included 55 participants so far. We will first see if they fulfill the criteria of the DSM, than if they are any different from those using medication. In a more in-depth interview we will question them on how they cope with their mood swings or vulnerability to mood swings. Best conversations ever so far.

Raymond here: I am a living experience of that reality!

I had 13x bilateral ECT for a psychotic mixed episode a year ago. My once awesome memory is now terrible. Is there anything I can do?

I am on lithium, levothyroxine, lurasidone and zopiclone. I also have an eating disorder (not currently underweight).

Paula Nunes here: The best way to improve your memory is to ensure that your thyroid lab exams are up-to-date and that lithium serum levels are ideal. Also, subsyndromal symptoms (residual symptoms) should be treated (as much as possible), including your sleep quality. Finally, mild-moderate physical exercise as much as possible (ideally 60 minutes 5 times a week) can be significantly helpful. If you can't do that much exercise it is ok, try once or twice for a start.

Does bipolar disorder also expand on a spectrum beyond I and II, depending on frequency and length of episodes?

Sarah here. Great question. There is a good deal of research that suggests that bipolar disorder exists on a continuum beyond just bipolar I and II. If you like reading about this, I would point you to the work of Hagop Akiskal who was one of the first to write about the “bipolar spectrum” extensively. Using this extended spectrum criteria, it is estimated that the prevalence of bipolar spectrum psychopathology is closer to 9% of the population. My work has also shown the same - that there are some people who do not neatly fit into the boxes of bipolar I and II but have many of the symptoms, or, they are at risk for the development to a more severe bipolar disorder later on. Note that not all individuals will go on to develop a bipolar disorder if they have these “soft signs” though! A good example is people who have a history of hypomanic episodes but never have had a depressive episode - they don’t meet criteria for bipolar type II. In the new Diagnostic and Statistical Manual for Mental Disorders (DSM - 5), we do have a category called “other bipolar spectrum disorder” where we can identify whether people have alternative presentations like: 1) hypomania with no depression, 2) short duration hypomania (lasting 2-3 days but not the full 4 days required for a diagnosis), etc. However, as a field, bipolar I and II definitely get the most attention. I’m trying to change that though!

I've read that risk of suicide it ~25% in people with Bipolar Disorder 1. Does this mean that a quarter of sufferers will successfully kill themselves, or just attempt it?

Also, how do you convince someone who thrives on the mania to accept medication? Don't they remember (in some cases) the psychosis and terrible aftermath and regret?

Erin here, thanks for your question. Bipolar disorder can be life threatening, but thankfully the risks of (completed) suicide are not as high as that. Some of the best data IMO in this area is being produced by the International Society for BD (ISBD) Taskforce on Suicide in BD. In this 2015 paper, they estimated the risk to be 164 per 100,000 person-years (about 10-fold greater than the general population, with higher risk in men). You can see the open-access paper here: https://pubmed.ncbi.nlm.nih.gov/26185269/

My mother is bipolar and has big mood swings at home, however, is able to control it while she is working. Would you be able to describe how or what people with bipolar do to cope with it outside of their house?

Andrea HERE - This is interesting. I have bipolar and do find that different environments and settings can really affect my mood. Maybe when someone is feeling hypo-manic or in an elevated state, they can feel more productive expending energy at work. Perhaps when at home, the environment is completely different and a person can feel annoyed and frustrated as the environment offers limited opportunities for focusing and expending energy. This is just a proposed scenario but environmental factors do affect mood. Perhaps a person holds all their irritations and frustrations at work, but this is not helpful or productive at all. I always feel that therapy is a great way in conjunction with meds to help manage moods and Dialectical Behavioral Therapy (DBT) helps slow the mind and ignite strategies for mindfulness. You can even purchase DBT self-paced workbooks to help: https://www.chapters.indigo.ca/en-ca/books/product/9781684034581-item.html?s\_campaign=goo-SmartShop\_Books\_EN&gclid=Cj0KCQjw\_4-SBhCgARIsAAlegrUZNsSym2KkTPRo--q3KepU8e-RrWnswlU4fJXRxH96pw\_QMzHGRBwaAgUJEALw\_wcB&gclsrc=aw.ds

One of the most popular portrayals of Bipolar in television is Ben in the Netflix original "Ozark". Curious if any of the panelists have seen that show, and if so what they thought of the actor's portrayal?

Rebekah here. Great question! I have seen Ozark and had conflicting thoughts about how Ben was portrayed. Many people have stated on Reddit that this was a very accurate portrayal of someone with bipolar disorder. I agree that there were many instances that I thought it was an accurate depiction, but the whole show is based on dangerous things happening very quickly. Those situations would be very stressful and it is hard to say how anyone would respond to the life and death moments that commonly take place on the show. I struggle with how individuals with Bipolar Disorder are portrayed in movies and media because there are often negative stereotypes depicted and I worry that the audience might get the wrong perception of Bipolar Disorder or mental illness in general. I think that it is important to remember that there are many people living with Bipolar Disorder that are not at all like the character Ben on Ozark.

Erin here. I personally resonated with Ben’s character in Ozark, as one potential representation of BD (from a myriad of presentations). He really struggled with the idea of needing treatment, which is common for some people, at least for a period of time, and was raw, vulnerable and kind. But I don’t live with BD personally, so will defer to other panelists on here who do.

Hi everyone, and thanks for doing this AMA! I live with Bipolar Type I, and I was diagnosed 10 years ago after a mixed episode with psychotic features.

My question: there’s a lot out there about mental health acceptance and awareness nowadays, particularly when it comes to anxiety and depression. However, I’ve noticed that the stigma continues for those with more severe mental illness, particularly those that feature psychotic episodes. How would you say that we can start to approach this stigma, knowing that many people don’t understand the complexity of psychosis, or even that psychosis can be a feature of Bipolar Disorder?

Thank you in advance for your time!

Erin here. Great question and you are 100% correct - research evidence tells us that BD is currently more stigmatized as a condition than depressive disorder, and that experiences of stigma are particularly high for people with psychosis. It’s much easier to “other” people who experience breaks with reality. Research evidence also indicates that one of the most effective strategies for addressing stigma lies in ‘contact-based approaches’, which basically give people the opportunity to connect with folks who live with stigmatized conditions to see that recovery is possible. We’ve done some work in this area, check out for example the one-person show created by Victoria Maxwell and our team “That’s Just Crazy Talk’ that significantly improved stigmatizing attitudes: https://pubmed.ncbi.nlm.nih.gov/25505692/

Do many others here suffer from social anxiety when not hypomanic? And find it goes away when. hypomanic?

Raymond here. Yeppers, that’s exactly what happened to me. I would feel invincible when super hypomanic, and when out of hypomania, my basic hyper sensitive and somewhat anxious personality would return.

Thanks for doing this today. Reading all the posts and replies is very enlightening. My mother has been had numerous psychiatrists and psychologists help her with depression and anxiety. My observation has been that she is bipolar 2 with periods of hypomania and severe depressions that last anywhere from 1 month to a year.

The “cycles” used to be every 3-5 years however now they seem to be much more regular almost perpetual as she reaches her late 70’s.

Does bipolar 2 get worse or more severe with the aging process?

A second question also comes to mind, is aggression and anger part of the hypomania? She gets very agitated at certain times and lashes out at family mainly but can “turn off” that part when around other people in her life that are not super close to her.

Hi Annemiek Dols here. Bipolar disorder does not fade with aging and often gets more severe/worse. However, often fragile somatic health may trigger episodes and increased vulnerability for side-effects may complicate treatment.

Yes, in older people agitation is a common symptom of (hypo) mania.

I am someone with depression who has infrequent moments of extreme energy and high self-esteem. I was once told by a psychiatrist that those moments are how non-depressed people naturally feel, but I'm not used to it because of my depression and thus it isn't mania. How does one differentiate between the two and how do I discuss the difference with a physician without them being dismissive?

Thank you for your work and taking time to do this AMA!

Erin here, our pleasure - thank you for the question. You would typically be asked whether these periods of high energy and high self-esteem are associated with any impairments or problems. Are you more at risk of making unwise decisions during those times? Do you do things you regret later?

Hi there,

Thanks for this AMA!

Any tips for helping someone with a recent diagnosis who's resistant to treatment? Any strategies that people have found particularly helpful?

They don't seem to have accepted the fact that bpd is a disease instead of something good that makes them special.

(BPD1 with delusions, et cetera.)

Natasha here – I have dealt with this both personally and professionally, so I’ve been on both sides of the equation. We cannot force anyone into change; it comes with patience and empathy. There’s a lot to come to terms with in understanding a new diagnosis – there’s aspects of shame, guilt, uncertainty, anger, etc. that take time to process. From both a personal and professional perspective, it is important to recognize that experiences labeled as “bipolar” can be very positive and important for that individual and calling it a “disease” can be very invalidating, so we do need to take time to validate these experiences. I have a lot of clients who we would tend to consider chronically struggling with delusions, and the most helpful way to approach them in my practice is trying to understand where they’re coming from. I had delusions with my bipolar that were very positive for me, and when I finally met a professional who recognized that in me – that was when I trusted a professional enough to have the conversation around treatment options. People with new diagnoses of bipolar have a lot to deal with. Yes, some folks are doing things that we would consider self-destructive and/or harmful to others. We must still meet them where they’re at with empathy and patience. As both a patient and a practitioner, my bipolar is special to me (even though it’s been harmful to me) and I acknowledge this in my clients so that we can move away from seeing this as a disease and more as a condition that can be treated to support someone in finding optimal wellness and peace.

Can bipolar affect memory? If so, how do I improve my memory?

Lisa E here - Yes, there is a lot of evidence that people with bipolar disorder can have difficulty concentrating and paying attention over a longer time frame, have slowed processing, and have trouble remembering things. Not everyone has these cognitive symptoms and those who do may have issues in some types of thinking but not all.

Some research suggests that people who have experienced more manic episodes have the most problems with memory. Cognitive deficits are also more likely among people with bipolar disorder who have a history of psychotic symptoms (e.g., hallucinations, delusions) as part of their disorder. So, one possible way to minimize memory problems is to find a treatment that works for you to reduce the occurrence of manic episodes and psychotic symptoms. Some people find that they can overcome problems with everyday life caused by memory deficits using compensatory strategies, like making lists and notes, setting alarms, asking friends/family for reminders.

You may want to consider whether your memory problems are coming from trouble getting information into your brain in the first place (encoding) or from forgetting information that was already in there. If your problem is with encoding , it can be helpful to make sure that you minimize distractions when you are trying to take in information and repeat information multiple times to yourself while linking that information to something else (“My new co-worker’s name is Anna and she works in Accounting.”). If your problem is forgetting information later, then notes can be helpful.

There is more controversy about whether pharmacological, lifestyle, or brain training programs can improve memory. One area that has some decent support is sleep. Getting better sleep can help you perform better cognitively, so you may want to work with a therapist to regularize your social rhythms to promote more consistent sleep.

Hello! Thank you for this AMA. What is the best course of action to take when someone feels they might have bipolar disorder but is unsure if it is the case or just normal mood swings? Additionally, what is the threshold of concern that delineates bipolar disorder from normal mood changes?

Hi, Emma here. We all have times where we feel low and sad, as well as times that we feel more energetic or excited than usual. Determining when a change in mood crosses from ‘normal’ to a potential sign of bipolar disorder can be tricky. As a psychologist, the key things I’m looking for (besides the symptoms outline in the DSM) is how long they have been present (and what proportion of that time they have been present for), whether they cause significant distress, and whether they impact someone’s ability to carry out their usual roles in work, school, or social settings. For example, two weeks of persistent sad and guilty feelings, weight loss, insomnia, and difficulties concentrating, that causes someone to perform poorly in university, clearly goes beyond the range of the kind of sadness we might feel in reaction to everyday setbacks.
It’s hard to give specific advice about where and how to seek help, given that mental health resources differ from country to country. The usual first step would be to see your doctor or general practitioner and mention your concerns (it helps to write down a list of the changes you have noticed in yourself, as well as any relevant family history). Bipolar disorder is relatively more rare (2.4% lifetime prevalence) as compared to unipolar depression (16.9% lifetime prevalence) so sometimes GPs are not as familiar with the condition, and may focus on the depressive symptoms (this is especially common for people who have experienced hypomania and not mania). If they offer you a diagnosis that doesn’t fit with your understanding of what’s going on for you, ask them why they chose it. Sometimes, it helps to hear a clinician pinpoint which of your experiences fit with the symptoms described in the DSM (especially as they are not always worded in an easy to understand manner - like psychomotor agitation, or pressured speech). If you’re not satisfied with their explanation, it’s okay to ask for a second opinion or a referral to a psychiatrist for their thoughts.
The other thing to note is that even if your mood swings don’t meet diagnostic criteria for bipolar disorder, if they are bothering you, it’s totally okay to seek help in managing them. Therapy is not just for people with diagnosed mental health conditions, it can teach helpful emotion regulation skills to anyone who is experiencing difficulties with their moods.

Is verbal abuse and constant nagging common when manic? How does one cope and stay calm in the face of bipolar rage?

Raymond here. Having experienced a manic episode coupled with rudeness, to the point of having difficulties controlling one’s physical and emotional impulses, my only suggestion is that there is no use getting into an argument, manic craves winning. So stay calm and protect yourself as necessary. Do not stay alone when your partner is in such a condition.

For people who have recently been diagnosed with bipolar disorder after having a manic episode, what is the probability that they will have another manic episode, assuming that they are on the right medication and are taking it regularly?

Hi, Emma here. I know of one large-scale study which followed people with bipolar disorder who were receiving treatment for two years after a mood episode. 48% of those people experienced another mood episode within that two year period, but it was much more common for those recurrences to be of a depressive polarity (70%) than mania. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.163.2.217
Another study (using the same sample) looked specifically at the participants who had a first episode of mania. This was a much smaller number of people (~100) so our conclusions do need to be more measured. But they noticed that while 58% experienced a recurrence within a year of their first manic episode, this was again more commonly depression (60%). https://www.sciencedirect.com/science/article/pii/S0165032715000361
That said, I should note that while both of these studies described the overall rates of recurrence, they did describe individual differences that contributed to the likelihood of whether or not a given individual went on to have another episode (for example, residual subsyndromal symptoms at baseline made it more likely that a person would experience a recurrence). So the statistics given above are not necessarily the probability that any individual who has a manic episode will have a recurrence - there’s lots of contextual factors at work.

My neighbor sometimes alternates between weeks-long phases of never leaving the house, to going out every night with a different suitor. Could this be a symptom of bipolar disorder? Is there anything I can do to help her? I just want her to have a harmonious life.

Victoria here - I can’t say for sure if your neighbor has bipolar disorder. But I can say those certainly were symptoms I dealt with. With depression, some days it was hard for me to even get out bed, let alone go outside. In mania, sexual promiscuity was an issue with me. The shame and embarrassment it caused me was enormous. I’d like to say to you, it’s wonderful that you are concerned about her and would like to help. Sometimes just showing that you care by asking how she is can open a conversation. If it feels appropriate non-judgmentally and compassionately saying to her that you haven’t seen out in quite awhile and wondered if things were ok can help too and telling her that if there’s anything she needs or would like to talk, that you’re there. Even if I didn’t take people up on their offer, it was comforting for me to know there was someone there if I eventually wanted to. Hope this helps!

What is the difference between bipolar disorder with psychotic features and schizoaffective disorder?

Lisa Eyler here - In the main diagnostic systems, those with bipolar disorder with psychotic features mainly experience psychotic symptoms (e.g., hallucinations and delusions) in the context of their mood episodes (either during mania or depression). Those with schizoaffective disorder mainly experience mood symptoms (mania or depression) in the context of their psychotic episodes. Thus, it is mainly a matter of degree: mood disorder with some psychosis vs psychotic disorder with some mood features. That said, there is not a lot of research to suggest that prognosis, treatment outcomes, or underlying causes are much different between the two, and many would say that these are very near to one another on a spectrum from “pure” mood disorders on one end to “pure” schizophrenia on the other end. My feeling is that you want to work to find the best treatments and lifestyle changes you can which improve the symptoms most impacting your daily life, regardless of the diagnostic label.

Hello,

I have two questions:

From my experience, people with bipolar disorder are less likely to stick to a medication regimen. Is there a reason for this?

Also, I am curious about bipolar disorder and pregnancy. I have been diagnosed bipolar for about 6 years and want to start thinking about starting a family. I have read that pregnant women are more likely to relapse with their bipolar disorder? Is this true and is there any way to prevent it?

Louise here. I have struggled throughout my 30 years with bipolar 1 disorder, with adherence to medications. I have been known to reduce my medication to below the therapeutic range, when I have been experiencing long periods of stability, only for the mania or depression to return. I have found certain side effects intolerable such as huge weight gain or sexual dysfunction. It took working with my psychiatrist and experimenting with different medications to find ones that produced the desired outcome with limited side effects. I eventually found a good regimen for me, so I always stick with it even if I am stable.

How would you advise someone newly diagnosed to bring it up at work? What cues should someone look for in determining if it's safe to do so or not?

Natasha here – Work disclosure still gives me stress, even though my colleagues/supervisor are all aware and treat it like just another fact of life. I was tempted to say I have a skewed experience as I work in mental health, but I have always worked in this field and I have had it gone extremely wrong for me before. I always try to “read the room” and explore the workplace opinions about mental health conditions before bringing it up. Safety for me has been trying to predict how others will respond to my disclosure. I also think it’s critical to know your rights in the workplace – know your organization’s policies and services, be familiar with laws that govern employment and disability, what supports exist for accommodations, if you know anyone with previous experiences with your organization, etc. If you are in the position of potentially meeting with discrimination, knowing your rights and entitlements is imperative. My negative experiences have definitely biased me in answering this question; I hate to say “prepare for the worst” but I also wish someone had told me this when I entered into the workforce. Hopefully that’s a useful perspective. I will also note that my current full-time job has been very accommodating, but I have been the driving force behind that and the aforementioned knowledge has been invaluable in determining the balance of safety (both for my wellness and for my visibility in the workplace) and disclosure.

Can bipolar people drink alcohol?

Hi Nigila here. Alcohol interferes with physical health even in people with no known illness.

The known effects of alcohol pertaining to bipolar disorder may be:

• Increase sedation
• Increase proneness for depression
• Manic episodes may occur following the initial euphoria. This can lead to hyperactivity, disinhibitions, judgment errors and risky behaviours.

Alcohol also competes with many substances, including food consumed by the body as they are also metabolized (broken down) by the liver. This may cause mild to severe interactions between alcohol and drugs. This means alcohol can either lower or increase the effects of medications used for BD.

So I was told by my mental health specialist that I'm probably bipolar.

What I was wondering is - can you be bipolar but have episodes that last only a few hours at most?

When I'd get angry or depressed, it wouldn't last real long, but seemingly longer than most folks and way more intense than the situation probably warranted. The person I'm seeing put me on generic Abilify and it seems to have blunted those feelings in a good way - I can get angry/sad/happy, but my emotions don't go to 100 and I calm down faster.

What's funny is that originally I went in to treat what I thought was really bad ADHD.

Hi, Emma here. While I won’t be able to make a comment about whether or not that diagnosis is right for you, I will say that strictly speaking, the Diagnostic and Statistical Manual of Mental Disorders (the diagnostic ‘bible’) defines an episode of mania as lasting at least 1 week (less if a person needs to go to hospital), hypomania as lasting at least 4 days, and depression as lasting at least 2 weeks. Cyclothymia is another diagnosis on the bipolar spectrum that involves the frequent experience of subsyndromal hypomanic and depressive symptoms for at least two years, but no more than two months of stable mood in between those times. It is possible to experience rapid cycling, which is defined as at least 4 distinct mood episodes in a given year, but many people anecdotally report more frequent mood changes than that. Ultra-rapid, or ultradian bipolar disorder (mood shifts lasting less than 24 hours), is not a distinct diagnosis in the DSM, so we don’t have as much research about it. However, some researchers are looking into whether it can be reliably differentiated from mixed features (the simultaneous experience of both manic and depressive symptoms), or borderline personality disorder (which is also characterised by short, intense shifts in mood). To tell these kinds of rapid mood shifts apart, a clinician would be looking at whether or not they are tied to daily life events, how extreme they are, whether a person experiences ‘euthymic’ (normal, balanced mood) in between these episodes, and how much of the time these symptoms are persisting.