Bipolar Disorder in the mirror: what you see and what you don’t
People’s relationship with their own mental functions is not always the same. Some people who suffer from psychological problems report them quite accurately; other disorders, however, are recognized through behavior, while the way people themselves present their condition is partial and sometimes distorted. Our brains perceive being anxious, excited, or depressed in different ways, because the eyes through which we see ourselves in our thoughts and behaviors cannot, in any case, see themselves looking.
In general, it can be said that the symptoms most frequently reported are anxiety-related or neurovegetative symptoms. The most commonly reported symptoms are anxiety, worry, insomnia, and various physical problems, ranging from pain to digestive disorders. A person who has only a condition of “pure” depression—that is, a general slowing of mental functions together with a lowering of mood—has a low probability of consulting a doctor, and of doing so as soon as they begin to feel unwell. If anxiety symptoms or insomnia are also present, however, the likelihood increases. It may seem paradoxical that a depressed person does not complain about their depression, yet someone experiencing “typical” depression experiences it as an abnormal condition that nevertheless has its own “logic,” as though there were no point in trying to change things. Hopelessness and pessimism are neutralized by passivity, by the tendency to reject or fail to seize opportunities, by generalized distrust, and sometimes by ideas of guilt, inadequacy, and ruin. In short, the classic depressed person does not “see” themselves as depressed, but only as unfortunate, in a way that seems logical, deserved, or at least impossible to change. What often “moves” the depressed person to seek help is the anxious component, and they do not hope to feel better beyond simply eliminating the anxiety.
There is a different form of depression, known as “atypical” depression, in which the tendency to seek help is greater because mental functions are usually not inhibited, but rather there is an “ego-dystonic” lowering of mood: the mental function that allows us to feel the absence of a gratification that would be possible is still present, but that gratification seems distant and difficult to achieve. People with atypical depression see themselves as depressed and describe themselves as depressed; even if the condition lasts only a few days or a few hours, they cannot tolerate it. People with atypical depression often, even outside the actual depressive episode, tend to call “depression” even the mere presence of transient depressive feelings, such as sadness, disappointment, or demoralization following some negative event. They may fear a relapse because of even a brief fluctuation in mood. People with “typical” depression, on the other hand, when faced with a diagnosis of full-blown and persistent depression, often disagree that their mood is low; instead, they see their condition as understandable in light of a reality of ruin and despair.
When depression is bipolar in nature, things become more complicated. People with bipolar disorder, especially in attenuated forms, tend at most to conceptualize the disorder in terms of bipolar depression. Usually, however, they present themselves as “depressed,” “chronically depressed,” meaning that they neither recognize nor report the excitatory component of their disorder. When mood is low, excitability is described as “anxiety,” whereas when mood is elevated it is not reported because it is identified with a normal condition—that is, something desirable and gratifying, or at least associated with greater vitality. A diagnosis of bipolar disorder is by no means among those diagnoses that patients readily accept, because it introduces a perspective opposite to the one dictated by their own awareness of the disorder: one centered on excitation rather than depression. This is also influenced by the confusion between excitation and euphoria: bipolar disorder may consist of depressive phases alternating with agitated phases, in which mood remains depressed but the level of motor and mental activation, as well as intolerance and restlessness, oscillates between inhibition and excitation. It is in this instability, and in the thoughts and choices that alternate between phases, that the concept of bipolarity becomes apparent.
For this reason, patients should not think in terms of isolated “up” or “down” phases, but should understand bipolar disorder as something fundamentally different from depressive illness. It is recognized by the damage that fluctuations between inhibition and excitation cause to personality, to the relationship with the world, and to one’s own life goals.
One of the major communication breakdowns between doctor and patient in bipolar disorder occurs because the patient feels as though they are being “accused” of having periods of excitation. They do not see anything pathological in them, or they see only the depressive symptoms, while the excitatory symptoms represent the subjectively normal part and therefore do not seem worthy of being placed at the center of attention. Consequently, the patient may not understand why the doctor focuses on the excitatory component, especially when it is not an obvious or euphoric form of excitation, rather than on the depression.
People with bipolar disorder often have what are called “comorbidities,” meaning that the same illness can affect different organs or different parts of the same organ. There is always a central component, with others varying from case to case: some people have bipolar disorder together with panic attacks, obsessive symptoms, or social phobia. These individuals usually seek help because of the anxiety disorder and only secondarily report features that point toward the underlying diagnosis.
In some cases, the onset or worsening of anxiety symptoms is considered a “depressive equivalent,” that is, an indicator of a reduction in mood activation levels. This does not necessarily manifest as classic depression, but rather as a condition characterized by phobia, social withdrawal, insecurity, doubt, or various fears that correspond to the structure of an obsession, social anxiety, or panic.
Depression, understood as a disorder, should therefore be conceived not so much as sadness or melancholy, but as de-tension—a decrease in tension within a system that regulates various functions, ranging from mood itself to sleep, the speed of thought, repetitive checking thoughts, and susceptibility to alarm reactions.
Finally, as is the case with many disorders, the way in which the human-environment system is perceived tends to privilege the environment because the brain is invisible to itself. In other words, people tend to attribute their distress to external circumstances rather than to their own internal vulnerability.
In conclusion, some forms of self-diagnosis are theoretically more reliable, although it is generally good practice to avoid self-diagnosis. Patients experiencing panic, for example, are reasonably likely to recognize themselves in a list of panic symptoms. This is not necessarily the case for people with mood disorders, who may identify their condition either in a series of external factors that they regard as the cause of their distress, in hypothetical forms of “stress” invoked retrospectively, or in a supposed vulnerability to depression.
Broadly speaking, patients who recognize themselves in the descriptions of depression found in clinical manuals are reasonably likely to have some form of bipolar depression, whether pronounced or attenuated. “Purely” depressed patients, on the other hand, are generally identified more accurately—and earlier—by family members.
Attitudes toward treatment reflect this same bias. The stereotype is that depressed people do not see the usefulness of antidepressant medication, regarding it as an artificial intervention that “doesn’t change anything” and may at most sedate them. Depressed patients therefore tend to spontaneously prefer anxiolytics, which can paradoxically promote or worsen depressive states. This choice tends to suppress the anxious component, which, as mentioned above, is more readily perceived as something foreign or extraneous to the person’s condition.
People with bipolar disorder, when they manage their medication independently, or when their suggestions about the composition of their treatment are simply followed, inevitably tend to put together combinations of antidepressants and sedatives, attempting to find the right balance between anxious excitation and excessive sedation and inhibition. This type of combination can worsen a number of mental functions and the course of bipolar disorder. Obviously, if depression is the only part of the illness that is “visible” to the person, antidepressants and sedatives may seem like a sensible choice. From the doctor’s perspective, however, and in terms of the illness as a whole, it may be the worst choice of all.
When an antidepressant produces an unsatisfactory response, people with bipolar disorder tend to think that there must be an optimal antidepressant; similarly, when faced with anxiety, they assume there must be an optimal sedative. People with bipolar disorder generally have little interest in the category of “mood stabilizers,” because this category does not fit their perception of the disorder. Paradoxically, they may come to regard antipsychotic drugs as useful because these medications can have both depressive and sedative effects, making them recognizable tools for achieving an immediate function.
“Lifting” the mood and “bringing down” the anxiety, according to immediate needs and circumstances, becomes the strategy of a person with bipolar disorder. This is the opposite of what the doctor tends to do: establish an overall preventive balance, keeping fluctuations within limited boundaries.
In general, a person with bipolar disorder believes that the way out of their disorder is the same as the way out of depression, and therefore involves “lifting” the mood. Excitation, whether euphoric or non-euphoric, is seen as a natural way out of depression, even though it carries risks, and therefore does not evoke the degree of concern it should. The person with bipolar disorder is much more affected by the aftermath of excitatory phases, yet remains exclusively concerned with the current depressive phase and with the possibility that it will return. In fact, they may even seek a stable state of excitation as a continuous “guarantee” that depression will not recur.
Ultimately, the person may believe that the guarantee of keeping depression away is a moderate state of excitation, whereas the reality is the opposite. At present, the safest and most reliable way to reduce the impact of bipolar disorder is to limit its excitatory phases in order to prevent the tendency toward subsequent depressive fluctuations, even if this may initially result in a period in which mood remains at a less-than-satisfactory level.
It is therefore important for patients to understand that their doctor is treating a disorder with which they cannot have a “mirror-like” relationship, because the mirror provides only a partial and distorted image. The common criticism that a doctor cannot treat a condition properly because they “should have experienced it themselves” is therefore not only unhelpful but also incorrect in psychiatry. The doctor has the advantage of a perspective that is closer to the functioning of the illness itself, in which symptoms are one component rather than its technical description.