If someone with bipolar 2 has a manic episode bc they were on the wrong medication, would that still be consider bipolar 2?
That would still be considered bipolar II provided that the manic episode doesn’t persist after the character is taken off the medication that caused it.
Hi! I have just realized that my main character has bipolar disorder (pretty sure it's bipolar I). I have major depression, so I'm familiar with the depressive side and I've done some research about bipolar I and II. Are there any harmful stereotypes I should avoid while writing her? And how do depressive symptoms differ between someone who has depression and someone who is bipolar? Thank you!
The biggest misconception / incorrect stereotype that comes to mind is the idea that the mood episodes in bipolar disorder change on a daily, or even hourly, basis. The minimum times to get diagnosed with a mood episode are:
“But Shrink!” you might say, “Isn’t there bipolar disorder with rapid cycling?”
Yes, but “rapid cycling” means that someone has four or more mood episodes within one year. That’s what is considered “rapid” when it comes to the bipolar disorders.
As for how depressive symptoms can differ between bipolar and unipolar depression the biggest potential difference that can happen is what’s colloquially called a “mixed episode,” but psychologists would call it a major depressive episode with mixed features. I’ve got an indepth post about it here, but the tl;dr version is that sometimes the depressive episode has elements of manic episode.
Some other differences:
The following things have also been found by some studies, but other research has not supported it:
I’ve also got a lot in my archives about bipolar as well; check it out here!
Can someone have depression, schizophrenia, and bipolar disorder at the same time? If so how would that work?
They can’t be diagnosed with all three of those disorders at the same time. They’re mutually exclusive.
Your character can’t be diagnosed with Major Depressive Disorder if they’ve ever had a full manic episode (which is required to diagnose bipolar I) or a full hypomanic episode (which is required to diagnose bipolar II). There’s also something known as a mixed episode, where a depressive / manic episode has elements of the other, but not enough to qualify for a full diagnosis.
There is a disorder that combines the symptoms of schizophrenia and major mood episodes - schizoaffective disorder.
Things get a little mushy when we’re talking about Bipolar I with psychotic features versus schizoaffective disorder.
The basic difference is that:
Schizoaffective disorder - at least two weeks of psychotic symptoms WITHOUT a mood episode
Bipolar I with psychotic features - only having psychotic symptoms DURING a mood episode, and having at least two weeks of a mood episode without psychotic symptoms.
Hope that helps!
Hi! Thanks for everything you do :) If a guy with bipolar is put on medication that sends him towards mania, would his doctor keep him on the meds to see if he even out, or would he immediately be taken off them? Thanks in advance!
From the Shrink’s impression, mania’s pretty much considered an emergency. The symptoms of a full manic episode are severe enough that they wouldn’t be kept on the medication.
I want to write a character (in the Percy Jackson Universe) that has extreme trouble falling asleep. However, they are a child of Hypnos, God of sleep. What illnesses would prevent them from sleeping? Insomnia or Nightmare disorder maybe? And (if you want), how would his sleep problems interact with the fact that their dad is the god of sleep?
Major Depressive Disorder has insomnia built into the criteria. Insomnia is also a possible symptom of a manic or hypomanic episode, as part of a Bipolar I or II diagnosis.
While not in the criteria, some anxiety disorders may prevent your character from sleeping because of their constant worrying. OCD could also work if your character is driven to perform time-consuming compulsions before they can go to sleep.
There is also a prion disease called fatal familial insomnia that causes insomnia; however, the lack of sleep caused by this disease is universally fatal, usually within one year after beginning to show symptoms.
In addition to insomnia or nightmare disorder, I have a bit of an unorthodox thing to suggest: central sleep apnea. Basically, the character’s brain forgets to tell their body to breathe while they’re asleep. While it doesn’t initially prevent someone from getting to sleep, it does mean that the character would be waking up frequently and not getting restful sleep. This may or may not work with your story, but I thought it’s a neat, unusual idea.
As for your last question, honestly, I have no idea. However, a certain proverb comes to mind: “The shoemaker’s children always go barefoot.”
Hope that helps!
The Scriptshrink consultants answer!
CW: Suicide, self-harm
It's... weird, and absolutely terrifying to be honest?
You get two kind of different presentations, one where you switch between pure mania and depressive symptoms rapidly, and another where the two almost occur together at the same time. I've only ever experienced the latter.
In my case, it presented as being absolutely miserable, but so agitated. In my "pure" depressive states, I'm tired and lethargic and can barely get out of bed. I have suicidal thoughts and I want to self harm, but because I just completely lack any kind of motivation, I can't act on these thoughts.
But when the manic symptoms kick in, it gets really frightening. I still feel as miserable, except now I have so much energy and my thoughts are moving so quickly that I end up thinking of countless ways to kill myself in excruciating detail, and these kinds of racing thoughts are just completely unstoppable. And it's scary, because I can literally see it in my head? All of the ways to hurt and/or kill myself are just playing in my mind like a movie.
I'd also have constant ideas coming into my head, really exciting things like projects I could start, which is a normal symptom of mania. Except because I was also horrifically depressed, I'd talk myself out of them. It was like my mania was suggesting one thing, but the depression would talk me out of it.
"I could go out and party/have lots of impulsive sex" "No you can't, you're ugly and no one wants to be with you"
"I could write a book!" "You have no talent and no one would read what you wrote"
"I could paint!" "You're awful at art and everything else".
And so on.
I also barely get any sleep, another common symptom of mania, but instead of still feeling energetic and not needing to sleep, I still feel exhausted. I usually can't sleep because my thoughts don't stop racing and I can't seem to relax enough to slow it down. And I can't sit still. So I'll eventually get to sleep at 4/5am after trying for hours, usually wake up about 2-3 hours later. If I do manage to get more than 6 hours, it's really restless, I wake up a lot, and I STILL feel like a truck has hit me the next day.
Also this is really outdated but I think it's one of the best, most in depth descriptions I've ever read: https://thesecretlifeofamanicdepressive.wordpress.com/2008/01/29/the-insane-guide-to-living-with-mental-illness-the-mixed-episode/
It's pretty atrocious.
It happens to me a couple times a year, and because I am GOOD by now at catching it early and I have safety measures in place, it never lasts long now. It feels like depression, but there's an agitated edge to it. I am more volatile emotionally.
I dissociate? I think? A little. What that looks like for me is having intense emotional reactions to things but having no connection to those reactions. Like, I might be crying wildly, but that's just my body doing it, and my mind is on the outside going "Whoa, damn, dude. That's pretty bad. You gonna be all right there, little buddy?" I can't stop it. I am not even, after a certain point, even feeling any distress, I'm just a passive audience. It sounds like that wouldn't be all that bad -- crying without feeling sad? -- but it's very bad, it's terrifying. I'm always afraid I might do something else while "out of it" like that, and I don't know if I could stop myself, the same way I can't stop from crying. They are very frightening!
That weird dissociation? Also manifests as this dull static in my head, nothing feels like it matters or is real, I can be in discomfort or pain, I can be hungry or have to pee, and I just . . . don't care. I don't care at all. All I want to do is lie in bed and do nothing, feel nothing. I do the bare minimum necessary to sustain myself. Drink, use the bathroom, sleep. I might do repetitive things like playing phone games or coloring in a coloring book (which can ground me) or do a puzzle. I have to seek out grounding things. Being around people helps, but I also hate it at that time because it's intrusive having to deal with someone else.
Mixed states make me feel helpless. I won't know what to do. My ability to make decisions, my executive functioning, goes straight to hell. I won't be able to make myself food. Asking for help is VERY hard, as I always feel like I'm in the way or unwelcome or am being unreasonable. (That's a feature of depression, but when you add the agitation, it's SO UNPLEASANT because there's this insistent feeling that I NEED help, I really NEED it, but I can't ask for it.) I am miserable and desperately want to ask for help, but it's very hard to do so, and I don't always know what I need, which makes it harder.
I can tell one is coming on because I get agitated and irritable. I get restless. I want to DO THINGS but I also get bored more easily. I start having trouble getting to sleep -- I just don't feel tired. The not being able to sleep just makes it worse. They can, in fact, be BROUGHT ON by a lack of sleep, even for just a couple of days. This is why, when people try to get me to do things that require massive schedule upheaval, I get so distressed. It might send me into a tailspin and I could go into a mixed state and I just . . . fucking do not want that at all ever.
When I feel one coming on, I notify my loved ones that I am going to need help with basic things more often, I start enforcing medication/bedtimes, step up the dose of my mood stabilizer, and, ideally, notify my doctor if I have one I trust. (I currently do not.) This is usually enough to bring it down in a few days or a week, and it's not that bad if I catch it early.
Treated, they typically last from a few days up to a couple of weeks before I get them under control. I'm very good at it by now, and my routine works. When I feel stable again, I drop my dose back down and see how I am doing.
NOT treated, they may not end for weeks. Had one a couple years ago that lasted like 3 months because insurance didn't want to pay for my goddamn mood stabilizers, and they are what keep me from having them. I almost hurt myself and I am still very very very angry about it.
Mixed states are just garbage and I HATE them.
hi and thanks for your blog, it's such big help! I have a character who, as I was thinking, have a bipolar disorder II, but recently it's came to my attention that at least once he had a hallutinations when probably had a hypomanya episode. It's should make it's mania, right? And than he have bipolar I? But can he still have like... mostly hyromania and see hallutinations reeeally rare or even not at all? Or it's not even mania's simptom and I sould look up something else? thank you!
If there are psychotic symptoms (in your character’s case, hallucinations), it’s a manic episode. Your character would be diagnosed with Bipolar I, even if they only have a single manic episode in their entire life.
Heya!! First off, thank you :) second, does medication for straight up depression make manic episodes worse in a bipolar person? (Type ii if that matters?) I've gotten contradictory results from my own research and would appreciate your expertise:) thank you again!!
You’ve been getting conflicting answers because there are a lot of different groups of medications that can be used to treat depression. Many antidepressants can make mania worse, or even induce a manic episode - but not all of them do.
All medications under the antidepressant umbrella have the potential to “switch” someone from depression to mania, with different levels of severity depending on the person. There are some antidepressants that some research suggests are less likely to trigger a manic episode or to induce psychosis. Someone with a bipolar diagnosis is more likely to be treated with caution when using an antidepressant, or not treated at all with them – it depends on the psychiatrist.
It’s a highly contentious topic. You can find researchers who vehemently disagree antidepressants cause mania, and you can find researchers who conclude antidepressants shouldn’t be used at all in people who have bipolar. And then there are studies in the middle, which aim to understand who exactly is at risk for antidepressant-induced mania (bipolar diagnosis or not). If you really want to get your hands dirty with this issue and see how complicated it is, you can take this article as an example.
My thoughts on this issue is it’s completely dependent on the individual and the antidepressant. From what I’ve read, there isn’t a consensus in the way of knowing how someone is going to react to any given antidepressant. From my personal experience, I take an SSRI (selective serotonin reuptake inhibitor) and it helps my depression and anxiety quite a lot with no negative side effects. But yeah, some people do have a manic switch, even if they have unipolar depression. I took a different type of antidepressant once and that was a steady climb into the manic zone. So it totally depends.
Thanks for your addition to this post!
There needs to be an continuous period of time where the character has a major mood episode (major depressive or manic) while meeting Criterion A of schizophrenia.
Let’s look at the other demystifying posts I’ve done to see exactly what that means.
In a two-week period, the character needs 5 or more of the following symptoms. These symptoms need to be different from how the character usually acts.
NOTE - for schizoaffective disorder, #1 is required!
These symptoms cause the character significant stress or make their life more difficult in some way.
It’s not because of another medical condition or substance. Make sure not to include symptoms that are clearly part of another medical condition (such as excessive sleepiness due to a sleep disorder).
There needs to be a distinct period of time where the character experiences at least one of the following moods most of the day, nearly every day, for at least a week:
The character also needs to be consistently energetic OR increase their level of goal-directed activity most of the day, nearly every day, for at least a week. Goal-directed activity means that the character frequently takes on ambitious new projects without necessarily thinking it through or completing previous projects first.
While the character is in this state, they have to show at least three of the following symptoms (4 if their mood is irritable), which have to be a significant change in behavior from how the character usually acts:
These symptoms cannot be the result of a drug (such as meth) or a medical condition.
The character needs to have two or more of the following for a significant amount of time in a 1 month period.
NOTE - At least one HAS to be 1, 2, or 3. These are known as the “active-phase symptoms.”
Phew. That’s a lot of symptoms. We’re not done yet, though! There are a few more requirements.
The character needs to experience 2 or more weeks of delusions or hallucinations WITHOUT being in a depressive or manic episode.
The manic or depressive symptoms need to be present the majority of the time that your character is having psychotic symptoms.
It can’t be because of a medication / drug or another medical condition.
Heya!! First off, thank you :) second, does medication for straight up depression make manic episodes worse in a bipolar person? (Type ii if that matters?) I've gotten contradictory results from my own research and would appreciate your expertise:) thank you again!!
You’ve been getting conflicting answers because there are a lot of different groups of medications that can be used to treat depression. Many antidepressants can make mania worse, or even induce a manic episode - but not all of them do.
Yeah, it varies massively not even in the group of medication, but the medication itself and the person taking it.
For example - my first hypomanic episode was triggered by fluoxetine (prozac) within the first 3 weeks of me taking it. It’s an SSRI.
My second SSRI, sertraline (zoloft) had the opposite effect. I ended up feeling kinda “meh” all the time. Not depressed, but not hypomanic either. And that never changed.
But I have friends who have had entirely opposite experiences! A friend took sertraline and ended up hospitalised for mania, but fluoxetine had absolutely no impact on her mood.
It’s worth noting that psychiatrists will occasionally prescribe antidepressants to a patient with bipolar, if they’re in a severe depressive episode or they’re typically depressed with only occasional (hypo)manic episodes (which is common in most people with Bipolar II if I remember correctly). But they’ll be monitored closely during the treatment.
Thanks for your addition to this post! Take note, Anon!
Heya!! First off, thank you :) second, does medication for straight up depression make manic episodes worse in a bipolar person? (Type ii if that matters?) I've gotten contradictory results from my own research and would appreciate your expertise:) thank you again!!
You’ve been getting conflicting answers because there are a lot of different groups of medications that can be used to treat depression. Many antidepressants can make mania worse, or even induce a manic episode - but not all of them do.
How would you write a mentally ill character in a religious society? I'm currently writing a story, and it revolves around a government run by religious figures. A character experiences several underlying psychological issues as well as BP-I, but he receives no treatment because his society treats mental illness as a sin. What might happen if he goes completely untreated? How do you think his treatment in society would play into his manic and depressive episodes?
CW: suicide
Without treatment, bipolar tends to get worse - a lot worse. Manic and depressive episodes get more intense over time, and go on for a lot longer if the character goes untreated. Manic episodes can last from a week, to multiple months. Depressive episodes can last 6-12 months untreated.
Also, about 15-30% of people with untreated bipolar will commit suicide.
As for how society’s treatment will affect him, I can’t answer that without more information about the character and the religious society you’re talking about. I can’t imagine it having anything but a detrimental effect - it’s just the degree of which I’m not sure about.
CW: suicide
Basically, in a mixed episode, the character experiences the symptoms of a major depressive episode AND a manic / hypomanic episode at the same time.
While "mixed episode” is a common term, the DSM-5 actually doesn’t have a single diagnosis for it; instead, it has been split into “major depressive episode with mixed features” and “manic/hypomanic episode with mixed features.”
Here’s a visual guide type thing.
[[Image description: 4 lines of white text with different colored backgrounds. From top to bottom, “Major depressive episode” is dark blue, “major depressive episode with mixed features” is bluish purple, “manic/hypomanic episode with mixed features” is reddish purple, and “manic/hypomanic episode” is red]]
Essentially, people call anything purple a mixed episode, but nowadays psychologists like to be a little more specific about what kind of purple it is.
Note - if a character meets all the criteria for both a manic and a depressive episode, they should be diagnosed with a manic episode with mixed features. Mania always wins the tiebreaker.
The depressive episode (see criteria here) has some symptoms of a manic (see here) or hypomanic episode (see criteria here), but not enough for a full diagnosis.
Your character doesn’t have to have bipolar I or II to have this diagnosis; however, they’re at extremely high risk to develop a bipolar disorder in the future, and as such may be diagnosed with “other specified bipolar or related disorder” instead of “major depressive disorder.”
This requires 3 or more of the following symptoms nearly every day, more days than not, during a depressive episode:
These symptoms need to be observable by other people and are a significant change in behavior from how the character usually acts.
These symptoms cannot be the result of a drug (such as meth).
The full criteria for a manic episode (see here) or a hypomanic episode (see here) need to be met, and the character has to have 3 or more of the following symptoms, which have to be present in the majority of the days of the manic/hypomanic episode:
These symptoms are observable by other people and are a change from the character’s usual behavior.
These symptoms cannot be the result of a drug.
But these dry criteria don’t truly convey just how awful a mixed mood episode is. Stay tuned, Shrinky-dinks, for some posts about what a character having a mixed episode might actually experience.
Hi! I have a character who's bipolar, and originally I thought he was type II. He does try to commit suicide during a (I thought) hypomanic episode triggered by new medication. Since the attempt requires him being hospitalized, does that then shift the episode from being hypomanic to manic and him being type I?
Yes. If it had so much of an effect on him that he had to be hospitalized, it’s a manic episode. He’d be diagnosed with Bipolar I.
There needs to be a distinct period of time where the character experiences at least one of the following moods most of the day, nearly every day, for at least four days in a row:
The character also needs to be consistently more energetic or active for at least those four days.
While the character is in this state, they have to show at least three of the following symptoms (4 if their mood is irritable), which have to be a significant change in behavior from how the character usually acts:
These symptoms have to be a complete change from how the character normally acts.
The symptoms have to be noticeable by other people.
The symptoms cannot be severe enough to cause the character great difficulty in their occupation or in interacting with others.
The character cannot be psychotic - if they are, it’s a manic episode. The character also cannot need hospitalization - again, that’d be a manic episode.
These symptoms cannot be the result of a drug (such as meth) or a medical condition.
::::::WRITING ADVICE, NOT PSYCH ADVICE::::::
::::::THIS IS TO HELP YOU UNDERSTAND THIS ISSUE FOR WRITING PURPOSES, NOT TO HELP YOU WITH REAL-LIFE ISSUES::::::
This is a good breakdown.
I have bipolar II, which is characterized by hypomania and depression, not mania and depression. Hypomania is milder than mania, and is not all that disruptive, comparatively. (The hypomania I experience is pretty benign, to be honest.) Because hypomania isn’t TOO bad, this means that subjectively and medically my illness is primarily defined by the depression that comes with any bipolar disorder, and by the occasional mixed episode/mixed state. Most of the psych medication I am on is to treat the depression. (And it HELPS.)
There are a couple of things I want to emphasize, building on the above.
“The symptoms cannot be severe enough to cause the character great difficulty in their occupation or in interacting with others.“
Yes yes yes! If it is severe enough to do that, it is mania!
Also, while mania does not require the presence of psychosis, if there are features of psychosis present, it is not hypomania, it is mania, full stop. You can be manic without psychosis. You cannot be hypomanic with psychosis. (Also, y’all do your research into psychosis, please.)
Overall, what this looks like for characters who experience it, hypomania is what the name describes: a low-level manic-type state. Symptoms are in almost all ways the same, just not as severe, and may not be perceived as a serious problem by the characters experiencing it. They don’t carry the same level of risk as manic episodes, and can easily go unnoticed if the character in question struggles more with depression, to the extent that bipolar II is OFTEN misidentified as unipolar depression. (It happened to me.)
When treated as unipolar depression, that can lead to frustration as drugs for unipolar depression aren’t necessarily effective for bipolar disorders. (So if you have a bipolar character being medicated for depression, research it from the bipolar angle, and make sure their meds are used for bipolar depression. If you put a bipolar character on Prozac and say that it’s working, I’m going to make a face.) ANYWAY, a character with bipolar II with hypomania might very well be diagnosed with depression, and then find their condition is “resistant to treatment.” Which it might not be if it were correctly diagnosed in the first place!
Overall, hypomania is pretty benign. That’s not to say that it can’t be an impediment, it CAN, but not nearly to the degree that mania is. Mania MUST present significant impairment, or it isn’t mania. Hypomania MUST NOT. That is one of the most important things to remember when deciding how to characterize your character’s illness.
Speaking as a patient, and as someone who has shared space with other bipolar people, hypomania, like mania, can take a few days to “ramp up” and a few days to “ramp down.” Sometimes it can happen overnight, but in my experience, the onset of symptoms is gradual over a few days or even a week or more, and while the symptoms do not as far as I know follow a set progression diagnostically, they generally follow the same order for an individual. Learning these tells is what allows patients to deploy countermeasures such as increasing antipsychotic medications to stave it off, stepping up therapy appointments if necessary, buckling down on sleeping and eating schedules, and instituting measures to assist with remembering to take medications. Your character, if they are experienced at all with their own mental illness, will likely have developed some of these techniques.
Anecdotally, my hypomanic states are weird and sometimes uncomfortable, but not significantly distressing, and are often pretty enjoyable because the elevated mood and burst of productivity is welcome. I have known a heckuva lot of bipolar II folks who felt the same.
I have known only one bipolar I person who liked their actual manic states. They absolutely still caused him disruption and difficulty, he just didn’t mind it. Other people around him did, very much, and he eventually accepted treatment with medication, which helped a lot.
Also anecdotally, a hypomanic state can sometimes (but will not always) slide into a mixed state. That is scary, and is why I do try to control the hypomanic states at least a little, because even though my hypomania is all right, the mixed states are so goddamn unpleasant.
Looking forward to @scriptshrink doing a breakdown of a mixed state! That’s where the fun REALLY begins! *hork*
Additionally, diagnostically, I believe that if your provider catches it, having even one manic state will get you labeled as bipolar I, even if you never have another and all subsequent elevated episodes are hypomanic. @scriptshrink can you confirm?
Also, @scriptshrink, your post above was purely breaking down the diagnostic guidelines, thank you for that, but with that framework there to hang things on, do you have input/thoughts on the “at least four days” thing? Could you help people out with what is a more “typical” length for manic/hypomanic/depressed/mixed states in a bipolar person? And a more typical interval in between?
Thank you for all your hard work!
No, thank YOU for this awesome addition to my post! :D
Yes, having just one manic episode means your character would be diagnosed with bipolar I. Bipolar II requires that the character have no full manic episodes.
And yes, I’ll be doing a breakdown of “mixed episodes” (and how the DSM-5 splits them up) within the next few days, and a post on episode length soon-ish afterwards.
The character needs to have had at least one manic episode. See here for what criteria is required for a manic episode.
The manic episode / subsequent major depressive episodes (if any) aren’t better explained by any of the psychotic disorders (schizoaffective, schizophrenia, etc.)
That’s literally it. There’s nothing else required for a diagnosis.
There are a lot of possible specifiers, but that will be gone into in a future post.
The character needs to have had a hypomanic episode (see criteria here) AND a major depressive episode (see criteria here).
These episodes need to cause the character stress or make their lives more difficult.
These episodes aren’t due to a substance (like drugs) or another medical condition.
Man, it’s been a while since I made one of these posts! I’ve changed the structure of these criteria a bit from the DSM-5, but it’s all there.
There needs to be a distinct period of time where the character experiences at least one of the following moods most of the day, nearly every day, for at least a week:
The character also needs to be consistently energetic OR increase their level of goal-directed activity most of the day, nearly every day, for at least a week. Goal-directed activity means that the character frequently takes on ambitious new projects without necessarily thinking it through or completing previous projects first.
While the character is in this state, they have to show at least three of the following symptoms (4 if their mood is irritable), which have to be a significant change in behavior from how the character usually acts:
These symptoms have to be one or more of the following:
These symptoms cannot be the result of a drug (such as meth) or a medical condition.
