Q:  Bipolar Disorder - Does This Fit?

Dear Dr. Phelps,

I have had a mood disturbance of some kind since I was very young - about age 9. I'm 28 now. I have seen a dozen therapists, none of whom i liked and about half a dozen psychiatrists, none of whom were very thorough in sorting through my symptoms.

I have been diagnosed with a myriad of things, the most popular being ADD, Generalized Anxiety Disoder, Depression, and Dysthymia. When I've suggested to therapists that i have something more severe, they tend to think I'm being too hard on myself or anxious. Ritalin blew me away with it's amphetamine effects, which makes a true ADD diagnosis a little sketchy, don't you think?

i just found out last weekend that mania can be dysphoric. I was shocked.  Since high school I have had many "strange states" that I have always filed away as "one heck of a bad day" or "i've gone completely nuts" but never thought of mania because I wasn't euphoric. I never told a doc because these states felt *so* insane and also because they were so short lived I could usually ride them out.

Well, I got a grip and told my most recent doc and he's thinking my "states" sound quite a lot like hypomania. I checked out your web site comparing ADD to BPII and oh boy, do I ever fall on the side of BPII. And your one page questionnaire pegs me as bipolar as well.

My lingering doubt is this: these "states" generally only last for several hours, perhaps a whole day. My depressions last for weeks or months. Does this still fit?

Because my depression is so severe, and Zoloft works for that, I'm reluctanct to stop taking it or replace it.  But it has increased the frequency of the "hypomania". Is adding a mood stabilizer the best choice at this point?

thank you,

Dear Ms. S. Girl -- 
You can imagine that if nearly every possible variation of mood swings and anxiety/difficulty concentrating "fits" under the bipolar umbrella, that's a mighty big umbrella.  So big, you could wonder about how it can possibly be an accurate "diagnosis", if so many people with so many types of mood experience, fit under the same "label".  I.e. how can a person who has one clear-cut manic episode with grandiosity and high energy have the "same" condition as someone like you?!  

On the other hand, there are many mood experts who have described extremely rapid cycling, as little as hours (because there can be multiple shifts within a day -- so called ultradian, "beyond a day" cycling).  So if ultradian cycling is well accepted, which it is; and if intense, agitated dysphoria is accepted as a version of "mania", which it is; then one simply has to combine those two concepts to come pretty close to your experience.  Closer yet, when you take into account that I see people who have a brief "hypomanic" phase only once in a long while, like once a month, while the rest of the time they are experiencing something that sounds a lot more like sustained depression (although it can get fairly irritable and agitated at times within that phase.  Then, "boing", there's a brief phase of intense energy, racing around the house doing 6 things at once (and sometimes even getting all 6 done), talking fast, thinking very fast and very clearly, then sometimes moving on to a point where the thinking is becoming fragmented and not productive, and so forth.  And that happens just for a few hours, and only once in a while.  That rather sounds like you, doesn't it?  

Anyway, the point is to say "yes" to your question "does this fit?".  What you have could be a variation of "bipolar disorder".  I keep putting quotes around it because with symptoms like yours, our naming system is too rigid to encompass your experience -- so every "label" will be wrong to some extent.  Obviously this is the point at which, if you're ready, you just have to try some treatments (as you have done with the antidepressant) and see if they take you in the right general direction.  If a mood stabilizer approach does go in that direction, then you've probably figured out that the other "half" of that treatment approach would be to try gradually lowering your antidepressant.  All of this should be done with your doctor's advice and guidance and awareness; this is not territory to explore on your own.  (It is territory worth thinking through, and if you must do that on your own, so be it -- as you have been doing, obviously).  

You wouldn't have to try to do anything with your Zoloft until you were pretty convinced that  a mood stabilizer was helping (unless you want to try lamotrigine first; I wouldn't combine that with Zoloft; but I would take at least 4 months to taper off Zoloft, whatever approach you take).  

Good on you for having figured things out this far to at least as your "does this fit?" question.  You've probably figured out that if you were to ask 3 different psychiatrists that question, you could easily get three different answers.  Good luck to you. 

Dr. Phelps

Published August, 2001