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This article is part of the Science in Sci-fi, Fact in Fantasy blog series. Each week, we tackle one of the scientific or technological concepts pervasive in sci-fi (space travel, genetic engineering, artificial intelligence, etc.) with input from an expert.
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About the Expert
Jon Peeples went to medical school at the University of Mississippi and completed his internship at Dartmouth-Hitchcock Medical Center. He’s currently a third year psychiatry resident at the Emory University School of Medicine, where he plans to serve as a chief resident next year. He recently finished an upper middle grade science fiction novel and is seeking literary representation. You should follow him on Twitter.
BiPolar Disorder: What Writers Should Know
As a psychiatrist, I treat all types of mental illness. There are plenty of popular misconceptions about what mental illness looks like, but there seems to be more confusion surrounding bipolar disorder than just about any other condition. This confusion is amplified by diagnostic sloppiness on the part of clinicians. I rarely spend a day in clinic without someone telling me that he or she has been classified as “bipolar” by a provider in the past, but most of the time the patient is suffering from something else entirely.
Psychiatrists use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to make diagnoses. The DSM-5 is organized into chapters that group different diagnoses based on our understanding of their presentation and the neurobiology behind them. We’ve made tremendous strides over the years in appreciating how the brain works, but our knowledge of many aspects of mental illness remains primitive. Each diagnosis in the DSM-5 contains a list of criteria that must be satisfied before a provider can diagnose a patient with a condition. It’s essential to treat the condition that the patient actually has based on the DSM-5 rather than the condition the patient thinks he has or wants to have.
Since I’ve started writing, I’ve become more interested in how psychiatric conditions are portrayed in fiction. I went to a local bookstore a few weeks ago and asked for recommendations of young adult novels that contain elements of mental illness. An employee suggested Rainbow Rowell’s Fangirl, which turned out to be the highlight of my holiday season. I loved it. I sat down and devoured it like it was my mom’s green bean casserole. The main character’s father suffers from bipolar disorder, and Rowell does a wonderful job of showing what this can look like. She accurately describes manic symptoms and demonstrates a solid understanding of how the illness can impact friends and family members. The only problem is that I wasn’t expecting to read about a character with bipolar disorder because the bookstore employee thought that the father was suffering from OCD.
Let’s take a closer look at bipolar disorder.
Is bipolar disorder the same thing as mood swings?
Nope. At least, not really. This seems to be one of the most common misconceptions. Patients often come in and tell me that they have bipolar disorder because their mood can change from one minute to the next and the smallest thing will set them off. True bipolar spectrum disorders involve manic, hypomanic, and depressive episodes (see below) which last for days at a time.
What most patients with these minute-to-minute “mood swings” are actually experiencing is mood dysregulation associated with their personality structure and primitive defense mechanisms. This doesn’t mean the patients are any less sick, but making the right diagnosis has tremendous treatment implications. Patients with bipolar disorder almost always need to be on medication to control their symptoms over time. For patients suffering primarily from the mood dysregulation described above, therapy is the mainstay of treatment.
“Mood dysregulation” isn’t an actual diagnosis, though it’s seen in some of the personality disorders described in the DSM-5 (e.g. Borderline Personality Disorder). It’d take years to fully discuss all of the theories of personality structure, but I’ll try to give one example of how it might play out.
Imagine a child who’s living in an abusive household. He’s new to the world, and his life has been chaotic. He does whatever it takes to protect himself from the abuse. He may fight back, scream, run away. Sometimes the defenses work, and the behavior is reinforced. Eventually he grows up and moves out into the world. He’s no longer being abused, but when he faces the stressors of everyday life, he doesn’t know how to respond except to use the same defenses that he developed as a child. Screaming and fighting over minor insults leads to instability in his adult relationships and often contributes to feelings of depression or dissatisfaction.
Now back to bipolar disorder.
Types of bipolar disorders
The DSM-5 covers bipolar disorders in a chapter called “Bipolar and Related Disorders.” This chapter includes Bipolar 1 Disorder and Bipolar 2 Disorder, among others.
To be diagnosed with Bipolar 1, you must have had a manic episode. Patients with Bipolar 1 often have hypomanic and major depressive episodes as well, but these aren’t required for the diagnosis.
To be diagnosed with Bipolar 2, you cannot have had a manic episode, but you must have had both a hypomanic episode and a major depressive episode.
Other diagnoses in this chapter include Cyclothymic Disorder and Substance/Medication-Induced Bipolar and Related Disorder. Manic and hypomanic episodes can be mimicked by illicit substances such as cocaine, amphetamines, and methamphetamines. Sometimes prescribed medications such as steroids can lead to manic behavior.
Manic, hypomanic, and depressive episodes?
Now we’re getting to the meat of it. What’s important to point out is that to qualify for any of the following episodes, the collection of the symptoms must be associated with a change in previous functioning and cannot be due to substance use or another medical condition.
In a manic episode, you must see either elevated, expansive, or irritable mood AND increased goal-directed activity or energy. There’s a great example of this behavior in Fangirl. The main character’s father calls her in the middle of the night because he’s not sleeping and has plans to install a fireman’s poll to connect the upstairs bathroom to her bedroom. You may also see grandiosity, pressured speech, decreased need for sleep, distractibility, and engagement in harmful activities (e.g. buying a car on a whim, promiscuous sex). A manic episode must last seven days (or less if there’s psychosis involved or hospitalization is required), and it must be severe enough to impair social or occupational function.
A hypomanic episode has similar symptoms to a manic episode, but the symptoms only need to last four days. Other people are going to notice the changes, but, unlike manic episodes, hypomanic episodes aren’t severe enough to cause a serious impairment in social or occupational function.
A major depressive episode must have depressed mood AND loss of interest and pleasure for two weeks in a row. You also may see fluctuations in weight (more often weight loss), insomnia or hypersomnia, fatigue, guilt, feelings of worthlessness, and thoughts about death. The symptoms need to be severe enough to cause impairment.
Who gets bipolar disorder
Bipolar disorder is present in about 1% of the general population worldwide, but it’s more common in high-income countries than low-income countries. It’s slightly more prevalent in men. There’s a strong genetic component, and relatives of people with either schizophrenia or bipolar disorder have an increased chance of developing bipolar disorder.
The onset of Bipolar 1 is at about 18 years of age, and the onset for Bipolar 2 Disorder is in the mid-20s. It often isn’t diagnosed until later because it can look like Major Depressive Disorder or other conditions. Most people spend more time in a depressed state than a manic state, but the amount of time varies widely from person to person. There are also usually periods when people don’t qualify for any type of mood episode and are relatively stable. There are many commonly co-occurring mental disorders including anxiety disorders, conduct disorder, and substance use disorders.
Treatments for Biploar Disorder
There are many agents available to treat bipolar disorder, and it often comes down to the doctor discussing the risks and benefits of each agent with the patient and reaching a mutual decision.
Lithium and valproic acid are two agents that control mania well. It’s important to periodically check blood levels of these medications to ensure that you’re giving the patient enough of the medication without causing toxicity. Lithium also has an anti-depressant effect and has been shown to decrease suicidality in certain populations. Depakote is thought to have an anti-depressant effect as well, though this the data for this aren’t as robust.
Giving someone with bipolar disorder an antidepressant increases the risk of developing a manic episode, even if the person is on a therapeutic dose of lithium or valproic acid. That said, since many people with bipolar disorder spend significant time in a depressed state, antidepressant use in patients with bipolar disorder is a common practice. Some people agree with this practice while others don’t, but it’s worth knowing that it’s out there.
Antipsychotics are often used in acute manic episodes, but some can also be used long-term or for depression. The three drugs FDA-approved for bipolar depression are Latuda, Seroquel, and Symbyax (olanzapine + fluoxetine). Lamotrigine (Lamictal) is a mood-stabilizer that doesn’t control mania as well as lithium or valproic acid but is commonly used in bipolar depression.
How to apply this to writing
I know a lot of what I wrote above probably sounded like a textbook, but I think it’s important to be as accurate as you can when describing mental illness.
If you’ve considered creating a character with bipolar disorder, I hope the information above is helpful in guiding you through that process. The most important thing to recognize is that the “mood swings” seen in bipolar disorder are sustained periods of elevated or depressed mood, not something that changes from one minute to the next. Your character will probably have other family members with mental health diagnoses such as bipolar disorder or schizophrenia, and the character will usually develop the condition in her late teens or early twenties. Medications can be helpful in controlling symptoms, but people often don’t like taking them because of the side effects or “feeling numb.” Unfortunately, many people decompensate without medication.
Toward the end of Fangirl, I was worried that the main character was going to develop bipolar disorder, like her father. She was the right age, and there was occasional decreased need for sleep and increase in goal directed activity. I don’t know if Rowell wrote it that way on purpose, but it certainly added to the tension when I read it. By describing mental illness accurately, she made it much easier for me to buy into her story and to enjoy it from beginning to end. A little bit of research can go a long way in making your story believable.
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I write non-contemporary and speculative fiction. Is there any physical harm that might happen with no treatment? I mean outside of the potential for self-harm or suicide. More along the lines of hastened physical deterioration, I guess. Early natural death? Internal issues?
And would you have any suggestions for researching what sort of pre-Industrial Age “treatments” might have been used? I know that may sound odd, but people might want to “fix” a comrade or relative without throwing them into Bedlam (which I wouldn’t be at all surprised to find out happened on regular basis). Calming teas in a manic stage? That sort of thing, anyway. If I were to write such a character, I’d like to make that part of it accurate if I can.
Dee,
I’m not totally sure. I haven’t looked into much of the history of bipolar disorder. Most of our treatments today are fairly new (though some [like lithium] are old as far as drugs go). I’m sure different things were tried in different places all over the world.
The other issue is that people who are manic often do not want to be treated. I could see people in the past trying to give someone who’s manic something that would put him or her to sleep. I’m sure many manic people in the past got arrested.
People with bipolar disorder have a lower life expectancy. Some of this comes from suicide, but there are other things that make it lower. People with depression often don’t take care of themselves physically. They may eat too much or too little. They often have low energy and aren’t exercising. That can certainly lead to worse health. People who are manic may do risky behaviors that aren’t necessarily “self harm” or “suicidal.” They may overuse substances, engage in risky sex practices, get into fights, etc. That all can lead to deterioration as well. There are certainly some brain changes that occur in people who have bipolar disorder, but the physical deterioration is usually due to risky behavior or not taking care of oneself.
Hi Jon,
You may want to consider checking out the book Anatomy of an Epidemic by Robert Whitaker. It looks into the histories of a number of mental illnesses, Bipolar disorder included, and it cites a large number of studies that have been conducted over the last 50+ years. In 1950 before psychiatric medication came into use, Bipolar disorder was not a chronic illness, and it was actually exceedingly rare for someone to have more than 3 episodes in their lifetime. It’s only in recent years, since the introduction of antipsychotics, antidepressants and mood stabilizers, that it’s turned into a lifelong illness.
There have also been quite of few studies that have shown that people off of medication live longer and significantly healthier lives than people on medication. This includes individuals with schizophrenia, as well. I know that’s completely counter-intuitive and counter-culture. It rubs me the wrong way to say it, since I’ve been on medication for type 1 Bipolar for the past 4 years and have been a strong pro-medication advocate ever since I was diagnosed. But the evidence that Whitaker cites is very hard to argue with (not to mention upsetting for those of us who have been blindly trusting our psychiatrists). If you take a look at the properly conducted studies, it’s unpleasantly clear that psychiatric medications have caused significant harm to the general population. I know that sounds like something a rabid anti-pill quack would say, but as a 100% compliant patient from day one and the daughter of a pharmacist, I am neither. I’m still trying to wrap my head around the idea myself. It’s been a very uncomfortable discovery.
Don’t take my word for it. I strongly encourage you to look into this, especially given that this is your intended profession.
Excellent work with the article, by the way. The disorder is often completely misunderstood and thus misrepresented. It’s nice to see something like this put out there.
I’ll have to check it out. I wouldn’t be surprised at all if there were increased rates of DM II, stroke, high cholesterol, etc. with antipsychotics as those go along with the second generation antipsychotics. Lithium certainly has its side effects as well. That’s why it’s so important not to prescribe these medications to people who don’t actually have bipolar disorder. I’d imagine that there’d be a significant increase in morbidity and mortality and a decrease in quality of life.
If people aren’t having trouble, I don’t want them on medications. If people are having trouble, that’s when the medications are helpful. I’m not opposed to people who’ve had single episodes carefully tapering off of medication because I agree that the medications can be harmful over time.
I find it strange that psychiatry will interfere with people’s lives because they don’t behave as society expects them to, but they won’t do anything about the people that manufacture and sell arms, politicians and government officials whose policies are detrimental, or the leaders of corporations whose quest for profit result in damage to the environment, all of whom ruin millions of lives. The bigger issue is psychiatry’s apparent charlatanism and hypocrisy. Hopefully medicine will progress to the point where the actual illnesses will be discovered and psychiatry will be absorbed by the other specialties.
If writing science fiction that takes place further in the future it might be more interesting to address how science had made breakthroughs and for example the old disorder of schizophrenia can actually be caused by one of three illness. Add a little about gene therapy and the existence of several cultures who are against that form of treatment and you can have a character from that culture struggling in the therapy-accepting culture whether from having an illness or having to help someone who has an illness but their philosophy is at odds.
I think one of the most important parts of psychiatry is only helping the people who want help or are having trouble functioning. If someone is hypomanic, but everything in life is going great and he hasn’t struggled with depression in the past, I’m not about to force treatment on him.
I’m here to help the people who aren’t doing great. People with mania and hypomania often struggle with depression following their “highs,” and providing mood stability helps them over time.
I’m not sure what psychiatrists would do with regard to arms dealers, corporate leaders, etc. as that’s a much larger societal issue. In a futuristic novel, I’m sure a society could find a use for psychiatrist to address some of that, but that’s not the way our world is set up.
There are clear brain changes in schizophrenia, bipolar disorder, depression. They’re real illnesses. And, sure, we have a really long way to go. What we’re describing now are symptom clusters that have a biological basis, but I don’t think you’ll find a psychiatrist out there who thinks that what we call “schizophrenia” is a single, clearly defined illness. As you mentioned, it’s likely a combination of a few different conditions that share similar symptoms. Hopefully we’ll be able to learn more about the causes of schizophrenia and find ways to prevent it.
I figured I had to weigh in, as a writer who also has Bipolar Disorder. I’ve never written a character with a severe mental illness, but after reading this, I’m wondering if it would in fact be rather cathartic in a way to attempt it. To shift and explore my own disorder and experiences outside of myself, to find a way to express these struggles (and rewards) in a creative fashion–I think it would be bloody difficult, but bloody enlightening in the end. Some pieces of myself and my history feel too painful to recall. But what is art for but to break and learn and heal, in the writer and the reader?
As to the questions of treatment, I have lived both ways and in between. When I was first diagnosed, psychotherapy and medication were absolutely necessary to both save and “normalize” my life. What some healthy people don’t always realize is that treating mental illness is not just about “fixing” one’s state of mind so that it looks and functions properly to the outside world. Sure, that’s a goal sometimes, just to protect my loved ones. But the pain that comes along with bipolar is far beyond mood instability. There is physical pain (especially in mixed states–I for one get the keenly real sensation that something is coiling around the base of my spine and flooding my bloodstream, pulse by pulse, with snake venom), vast psychic pain (imagine, for example, the sudden violent anguish that might occur if you were accidentally the cause of your beloved’s death–but in fact, it was only your brain chemicals flooding you with that pain for no real reason), not to mention the strain of being manic (imagine, again for example, the energy and excitement and thrill of going on a roller coaster, but you know that there are bolts missing from the rails and your seatbelt isn’t fastened, but you just did a bunch of coke so you DON’T BLOODY CARE). Not to mention the depression. It feels like your freaking cells hurt. Like your cells are whispering that it would be better to die. Like your cells are guilting you for being in pain.
Long story short. Mental illness really hurts but even as a patient, I can say it’s fascinating. When it comes to fiction, I’ve seen a few movies demonstrate mental illness well– Prime, with Anthony Hopkins and Gwyneth Paltrow is a good one–but most books I’ve read tend to misunderstand the nearly-existential difficulties. The instability is presented as theatrical or maudlin.
I imagine that planning a character with mental illness would involve some familiar paths–when was this character diagnosed? Were they misdiagnosed initially? How has this illness impacted their families? Psychiatry treatment is one thing, but is this character taking care of themselves or not? Much like with writing a character with a physical disability or an uncommon sexuality or gender identity, the writer’s gotta ask–how does this aspect of the character influence the story? What am I trying to say about the world as I write this character?
Writing a character with a mental illness is no different than writing any “normal” character, in a way. They deserve an arc, and they deserve growth. They deserve hardship and failure. But also, strength and triumph.
I agree very much so. I also suffer from similar. A bipolar disorder, still unsure as to the type. The psychiatrist has my chart, but even then, I’m not sure they know every detail of me.
I love that these things are being discussed, since I also want things to be accurate in movies & literature.
So, for my project in English class we have to write a story. Mine went many ways, at first it was about self harm, then it went to the main character having Bipolar disorder, then it went to teen pregnancy, now it’s back at the main charcater being Bipolar.
I’m stuck on it. I have read up on endless websites about the disorder and I understand it, but at the same time I do not. I understand all the types of episodes and everything else.
What I do not get, is what it’s like when that person goes in and out of an episode. Does a depressive episode come right after a hypo manic or manic episode? Also, how it feels, I’m trying my best to stay with the whole subject of ‘show not tell’ which means I have to do a bunch of describing. I find it really hard to do so, because I just don’t understand what it feels like.
My grandmother had bipolar disorder, not really sure which one, but I barely saw her. Sometimes she was just in a mood, and when I went back a month or two later she was happy to see and she was all talkative and it was fantastic. I guess that’s why I also have a hard time understanding it.
The most I can do is write about the depression parts of it, because that’s the only part I understand.
I have no clue if anything of what I just said made sense to you, nor do I know if you will reply, but I hope you do. I’m sorry for taking up your time, and thank you for reading if you are,
Hi Cassandra,
I thought the first part of your question was interesting. I don’t know the plot of your story, but there are tons of people with bipolar disorder who struggle with self harm. It’s very common. And many of them also become pregnant or are interested in becoming pregnant. You could incorporate all three of those into your character if it works for the story. I don’t think that any one of those things alone makes a story. They’re all details and sometimes obstacles, but it’s how your character interacts with them and struggles with them that will be important. I think it’s worth figuring out what exactly your character wants, how she plans to get it, and how bipolar disorder makes her goal difficult to achieve (or how she has to achieve it in a non-traditional way).
People with bipolar disorder typically spend most of their time in either euthymic states or depressive states. People can certainly transition quickly out of manic states into depressive states. Many patients talk about a “crash” where they become extremely depressed after a manic or a hypomanic episode.
It’s really tough to understand what it feels like. I don’t even know exactly what it feels like because I don’t have bipolar disorder. It also varies a lot from person to person. Many patients have described to me feelings of intense anxiety and frustration without being able to slow down. It’s as if their thoughts are coming faster than they have the ability to organize them. Some people enjoy the manic states, but for others they can be really terrifying. The depressive states tend to be pretty similar to unipolar depression. Patients will often have decreased enjoyment in things they used to like. They’ll have guilt, suicidal thoughts, psychomotor retardation, depressed mood. It definitely feels differently person to person, so you could try to read some first hand accounts of people who have bipolar disorder or unipolar depression.
It’s an extremely tough job to write a first person story with a patient who is in a manic state, especially if you’re trying to capture the thought process of someone. I honestly don’t know of a good example in literature. It’s much easier to write from a depressive point of view or to write a story in third person. Your story could have a depressed person right after a manic state, and the person could be thinking back to some of what he or she did during the manic state.
That said, I think it’d be a great exercise to try to write from a manic point of view. I’d focus on the racing thoughts, the pressured speech, the grandiosity, and the risk taking. Remember, it’s all going to make sense to the person, so try to present it in a way that the objective actions sound inappropriate to the reader but the logic behind them makes sense to the person. People can be really happy during manic states, but they can also feel overwhelmed and distressed. There’s not a single right way to describe mania, so you have some freedom to work. Just make sure that the symptoms and timelines line up with what I described in the article.
Thanks,
Jon
I set out to do that very thing, to write a first person story with a patient who is in a manic state. I’m a little disheartened, as it does have difficulties. I like the unreliable narrator, but I also want to establish her as a decent person that sadly has experienced thoughts outside her control. The writing exercise has definitely been theraputic for me, as much of this is a late in life firsthand experience but I’ve found it’s tough to use analogies (I described her as a dog but some readers took this like she literally thought she was a dog.) People in the manic state can be annoying… so she is less likeable and seems arrogant when it’s really mania.
For me and my “research” into this time of my life, I could definitely see patterns of things that were said that showed up again in the manic state in some kind of fever – but I don’t seem to be doing the best job getting that out. Argh. One solution I’ve thought of is to layer her mania with a look back at a journal to show her normal state? but that seems clunky. What’s funny to me is i start her off in a “normal” state of mind and a few readers thought she was already manic. I’m not exactly sure why I comment except to agree that yes, it’s very difficult to write in first person. I can do short runs of mania but putting them together seems to be laborious for the reader, as they’re feeling the shakiness of it all and not necessarily enjoying the experience. It seems to start well, then some seem to want to throw the book against the wall. I want to put a real example out there, as the dramatic bipolar plots I’ve seen or read usually don’t resonate (if ever) but it’s tough!
I am writing a Bipolar villain character, I was wondering does Bipolar disorder increase aggressiveness and maniacal characteristics?
You may need to rethink that. Bipolar disorder alone won’t make someone villainous in that sense.
Agressive? Not really – a manic episode in a way amps up what the person is already like. It won’t make them more aggressive, but if they are already aggressive it may make them more likely to act on those tendencies (due to the poor decision-making and increased activity that are symptoms of mania).
Maniacal? Well the term does come from the word “mania” which is half of bipolar disorder. But I really don’t know what you mean by maniacal characteristics – what kind of characteristics would those be?
Source: I work in mental health, and I have cyclothymia myself. Also, DSM-5 for specific symptoms