Frequently asked questions

How can I be bipolar II and still have severe psychosis?

You cannot really have Bipolar II and psychosis at the same time. Given that these diagnostic definitions are descriptive really by definition one excludes the other. The presence of psychosis even if it’s in the depressive phase would categorise you as having Bipolar I disorder (if not schizoaffective or other psychotic disorders).
Keep in mind that psychiatric diagnoses may change over time. So maybe early on you were diagnosed with Bipolar II disorder and later for whatever reason you developed psychosis. This would then change your overall working diagnosis.
If your bipolar disorder is mostly dominated by depression as most do and your psychotic episodes are not combined with grandiose euphoria (happiness) then again you are likely to think that you have Bipolar II disorder.
Another possibility but this would require very careful assessment of your psychotic symptoms experiences may be that you indeed have a Bipolar II disorder but at the same time you also have Borderline personality disorder or something equally traumatic from your past. Borderline pds and also traumatic experiences from your childhood years may lead to severe intrusive memories that will exacerbate during depressive episodes. For some patients these intrusive memories may be so vivid and real that can be reported as psychotic symptoms.
On this occasion the treatment would have to be modified and be directed more towards the issues of your traumatic experiences and possible personality disorder (Structure).

Does bipolar disorder require manic episodes to be diagnosed as such? Can fluctuation between normal and depressive be just depression?

Good question.
NO it does NOT.
Strictly speaking the bare minimum one would need for a diagnosis of bipolar disorder would be one hypomanic episode and one depressive episode (bipolar II subtype). However there are bipolar subtypes that fall in the bipolar spectrum that may only have fluctuations in the depressive pole.
For some this may be a debatable practice and critics argue that this leads to an inflation of the bipolar diagnosis but in practice in the hands of a bipolar expert this is helpful. Atypical depressions or depressions that may have highly relapsing courses can be improved greatly if they are treated as mood episodes of a bipolar condition.
The alternative route may often lead to a worsening of these “depressions”. If one is lucky they may develop a manic episode, and very soon realize that their depression was more than just a simple depression. The unlucky ones end up with depressions that don’t respond to treatment, they become mixed states, they fluctuate more and continue relapsing.

So all in all in many ways not needing a manic episode or even a hypomanic episode for ending up with a bipolar diagnosis can be lifesaving.

How do I survive a bipolar 1 mixed episode?

Great question and indeed mixed episodes can only be survived as they are horrible to experience.
I will try to be brief and concise. It is very important to understand mixed episodes. You have the worst of a depressive episode and the worst of a manic episode together. First it is important both for the patient and their clinician or treatment team to understand that this is a mixed episode. These tend to be very confusing states. On one hand you may have the energy and hyperactivity of a manic episode, and on the other hand you have the dysphoria of the depressive episode.
Once this is identified correctly, it is important to make sure that the bipolar patient is safe. Mixed episodes usually come along with suicidal ideation, and it is the most risky bipolar state for someone to actually act out on these thoughts and feelings. The hospital setting is usually the safest place to treat initially the mixed episode (I am not referring to mixed states here - I am referring to much more extreme mixed episodes). Then treatment. Fortunately we have a number of good medications that treat quickly and very effectively the acuteness of the mixed episode. Depakine, Quetiapine or their combination are usually the best candidates. The medications need to be able to “burn out” the manic side of the mixed episode first. The use of antidepressants or other stimulant medications is always a big NO. Anxiolytic medications may be used but only for a short period of time.
Once the manic side has been burned the patient needs to be aware that the next phase of the treatment will target the underlying depression of the mixed episode. Again it is always best for the patient to know this in advance so they can realise how the treatment is progressing well.
“If this is helping me then why am I depressed? Answer: Because that’s the natural treatment cycle of a mixed episode. We will slowly start treating the depression too, but we will also make sure that we don’t make you mixed/manic again.”
If the patient has understood this process in advance there will be some level of trust to accept that a depressive phase is good progress towards recovery.
Third step. Treating the depression. We go slowly. We use psychotherapy. We use medications that do not have the potential to re-activate the mania. We avoid antidepressants. Good options would be CBT, Behavior activation therapy with mindfulness and relaxation training, and medications like lamotrigine, and seroquel xr. A slow and steady recovery is always best than a fast and unsteady recovery.
Once the depression resolves then it’s also the end of the mixed episode. Again the patient needs to continue with prophylactic treatments that have a very low probability of re-activating mixed states or increase the mood instability. The lifestyle also needs to be prophylactic friendly (low stress, no stimulating substances).
Life may not be as exciting but with time life will be stable and valuable once again. The mixed episode will only be, and rightly so, a nightmare of the past.

Are the awareness programs of mental disorders like OCD, bipolar disorder, ADHD, BPD and depression a marketing stunts by doctors and psychiatrists?

Of course there are corporate interests, no one can or should deny of this reality. There are many scientists in our field who are doing great work in discussing and researching these corporate interests (see Dr David Healy’s and Dr Joanna Moncrieff work). But at the same time, the short answer is that despite any type of corporate interests, these labels refer to people who have problems in their life and suffer a lot. The spectrum of mental disorders is wide enough to accommodate people who can handle things on their own, but also others who need to have continuous treatment to get and remain well. This is the case also with the whole range of Bipolar disorders. Awareness programmes hep people to start learning about these problems, and to make informed decisions about their treatment choices. I believe that most of our patients are in a good position sooner or later to understand what’s is best for their health, and to distinguish between corporate stunts and sound psycho-educational campaigns. If you have been given a diagnosis but you can still make it on your own, then this is great news for you. Unfortunately, not all people can do it on their own, and this is where our help is needed and requested. Good luck with your scepticism. I hope it becomes constructive for you.

My psychiatrist has said I have had major depressive episodes and a hypomanic episode, but no mention of bipolar II. Isn't this the definition of BPII?

Yes indeed this is the definition of Bipolar II disorder - unless your hypomanic episode was drug/medication induced in which case your diagnosis would remain a major depressive disorder (or the informal bipolar 3 disorder).
On the other hand if your hypomanic episode was not a hypomanic episode but some interpersonal - personality crisis, then again your diagnosis would not necessarily be a bipolar II disorder.
But you do have a valid question for your psychiatrist. You can always ask him to clarify his thoughts about your diagnosis.
Remember to discuss with him the pros and cons of pursuing therapy for a major depressive disorder if you have a bipolar II disorder. In most cases you need to be extra careful with antidepressant medications that may complicate the course of bipolar II disorder.
In our specialist practice if we have any hints of bipolarity we tend to avoid these medications and to work with mood stabilisers and/or meds that have a very low risk of triggering mixed states, manic/hypomanic episodes or rapid cycling.

I was scheduled by mental health, then diagnosed with bi-polar. Isn't there supposed to be an extensive evaluation before diagnosis?

A diagnosis of a Bipolar disorder is indeed something that needs to be evaluated extensively and very carefully.
However, a working diagnosis may be reached at a much earlier stage depending on your current state.
We have one of the most comprehensive diagnostic programmes for Bipolar disorder, and this evaluation usually takes approximately 10–15 hours of clinical evaluations along with psychometric testing.
Nevertheless there might be situations when we will get to the diagnosis of Bipolar disorder right after a single consultation - especially if a patient has a very definite, and clear history of a manic episode (or manic episodes).
In most complicated cases our diagnostic programme will give us all the necessary information, but there may be more hidden and sub-threshold bipolar disorders that need to be evaluated in real time over a period of a year or so.
It is often difficult to detect-diagnose reliably hypomanic periods - episodes, mixed states or personality traits (borderline, narcissistic etc) by self-report. If you add to to this cocktail of problems, substance use or abuse or side effects from psychiatric medications, the diagnostic picture may become more complicated.
My two cents would be to try to work with your team, and to understand why you were given this diagnosis so quickly. They may feel it is urgent to proceed with your treatment or they may not have had the time to start explaining things to you. Try to talk to them and also it doesn’t hurt if you start reading about bipolar disorder.
Even though it may not be your diagnosis, it will not hurt you if you learn a couple of things about it. In the future you may have a relative or a friend with the disorder, who would most likely find your knowledge useful.

Suspended from work for sleeping. I am type 2 bipolar and forgot to take my medication I was very tired. Looks like it's time to find a new job?

It’s difficult to exactly advise you what’s best to do in your situation, especially if we do not know your full clinical history.
But in principle yes, getting a new job would be a great long term goal, but if you are currently still depressed my clinical advice would be to take it slowly.
It would be important first to address your depressive symptoms in therapy and to set goals with your therapist in order to become more active. Then once you see that you can still be functional enough it may be a good time to start looking for a new job.
Keep in mind that the majority of bipolar patients even when they are well are likely to suffer from low-grade depression and depressive symptoms (what we like to call sub-syndromal depression).
So, take it one step at a time. Address your depressive symptoms in your therapy first, and then start looking for a new job.
In we always start our new patients with an initial diagnostic consultation, and then depending on each patient’s clinical state we continue with either our full diagnostic programme (for those who are currently well) or with our CBT programme (for those who are currently depressed/mixed/hyper).

How can I deal with (or prevent) bipolar rage?

Thank you for your question. My experience with my bipolar spectrum patients is that they usually misinterpret the symptoms of their bipolar disorder with the typical reactions of their personality traits.

Provided that you do not get into such rages while you are hypomanic or mixed, then the issue would be with psychotherapy to address the underlying cognitions that give rise to such anger outbursts.

CBT, DBT, and Schema therapy are all good approaches for dealing with such behaviours.

Therapists who employ such methods will slowly help you to break down the automaticity of this behaviour. In we invest a considerable amount of time clarifying your diagnosis and individualising your treatment plan.

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