Bipolar Me

This question comes up all the time, about all kinds of public figures and various sorts of disorders. Does Donald Trump have Narcissistic Personality Disorder? Did Freddie Mercury have undiagnosed bipolar disorder? Do the Kardashians have Body Dysmorphic Disorder? Does Joe Biden have dementia? Was Nancy Reagan co-dependent?

Seven years ago, I wrote about Emily Dickinson (https://bipolarme.blog/2015/03/27/diagnosis-and-dickinson/). Then I said that it is impossible to know whether Dickinson or any other historical personage had any psychiatric disorder and, if they did, what it was. Now I have basically the same thing to say about the “diagnoses” of public figures.

It’s impossible to say whether any given celebrity – or indeed any public or private individual – has a psychiatric disorder unless that person has spoken about it publically. We cannot assume, just from the little we know about another person, that he or she lives with any given condition. This is true not just of psychological disorders, but also physical ones. In the past, it was easier to keep physical difficulties secret. Few knew that John F. Kennedy wore a back brace because of an old injury or that Franklin Roosevelt used a wheelchair because of polio. Only now that their memoirs or the memoirs of their friends have revealed these previously secret afflictions do we know about them.

When it comes to psychiatric diagnoses, the difficulty is not that friends may or may not keep a public person’s secret, but that the public has no real right to know unless the celebrity is open about it. The relationship between a psychiatrist and a patient is confidential. Only the patient can give permission for the doctor to disregard that confidentiality. Lately, it has become common for political figures to endure public examination of their medical records and even psychological records. But this is by no means a requirement for a public office such as president. Really, a president of the US only has to be over 35 years of age, be a natural-born citizen, and get the most votes. And such scrutiny is hardly a requirement – completely irrelevant – for entertainers and athletes.

Speculation about the private lives of public figures has reached the level of a sport. It seems that just because a person has achieved some measure of celebrity, their life is now an open book. Their fans (and detractors, for that matter) want to feel they have a personal connection with the public figure. They want to believe that they know the celebrity better than anyone else. They may feel a kinship with the person because they have the same disorder that the public figure supposedly has. But the most that you can say about a public figure is that he or she shows some behaviors that can be associated with a certain diagnosis – not that the person actually has that condition.

Some celebrated sports figures and actors have been upfront about revealing their own and their families’ stories of psychiatric illnesses. Catherine Zeta-Jones, Glenn Close, Carrie Fisher, and Michael Phelps have let such conditions be known, in hopes of reducing the stigma surrounding mental illness and encouraging others to seek help for their conditions. But these people are the exception. Most people, both celebrities and the general public, suffer in silence.

Basically, the only way to diagnose a person is for them to have an ongoing relationship with a psychiatrist or psychologist. A doctor who has spoken to the individual and spent time with him or her is the only person who can make that diagnosis. Even psychiatrists who testify at trials about the mental state of defendants may not have had any previous, personal contact with them. Yet their opinions help determine the fates of people they don’t really know.

Public figures don’t belong to the public, whatever their fans or detractors may think. Their minds especially are their own. It is reckless, improper, and ultimately futile to speculate on a public or historical figure’s mental state. But people do so and will continue to, as long as there are celebrities and people who feel they have a right to analyze them.

Bipolar disorder is misunderstood by many. There are many helpful, reliable sources on the internet that explain it well and many books that provide both psychological expertise and personal stories of living with bipolar. Still, the general public believes many myths about the disorder. Here are a few of them and the real information that can counteract them.

Bipolar is bipolar is bipolar. There are many types of bipolar disorder. The best known are bipolar 1 and bipolar 2. But there are also bipolar 3 and 4 – less well-known but still troubling versions of the disorder. Bipolar 3 is also called cyclothymic disorder. Bipolar 4 is bipolar due to another medical or substance abuse disorder. Each of these types of bipolar has differing symptoms – mania and depression for different lengths of time, for example – but they are not identical.

Hourly mood swings are symptoms of bipolar disorder. It’s common for people to say that their friend’s moods change rapidly, so they must have bipolar disorder. This is a misconception. Bipolar disorder is characterized by alternating periods of mania and depression, but these last longer than hours or days. They can and do last for months or even years. There are types of bipolar disorder that are called rapid-cycling and ultra-rapid cycling, but these forms of the condition still feature episodes of mania and depression that occur up to four times in a year. There is (or may be) ultra-ultra-rapid cycling bipolar, which can manifest over a day or two, but this is extremely rare.

You can “fix” someone with bipolar. No, you can’t. My husband tried to fix me, with no success. Perhaps because he had some experience as an aide in a psychiatric facility or because he had once led a laughter therapy group, he thought he could. He loves me more than anyone ever has, but I was immune to his attempts. When he offered advice, I told him to “quit shrinking at me.” When he told the same joke over and over trying to get a laugh out of me, I just looked at him. Even a psychiatrist and medication can’t “fix” a person with bipolar disorder. They can help to alleviate the condition and even help a person go into remission, but there is just no fixing bipolar.

Bipolar people end up hospitalized. Although some people with bipolar disorder are hospitalized, this is far from the only outcome for them, and many are hospitalized only for short periods. In fact, it can be very difficult to find a hospital or psychiatric facility when one is needed. The closing of many care facilities and the low number of beds available, along with insurance requirements, have contributed to this. Hospitalization is considered in emergency situations, such as when bipolar persons are an immediate threat to themselves or others. Outpatient treatment is preferred for all but the most extreme cases.

Medication, particularly with lithium, is the only treatment for bipolar. Lithium was the first medication to be used with bipolar patients, but it is now far from the only one. Medication (with a wide array of choices) is certainly an important treatment for bipolar disorder, but there are others. “Talk therapy” can help people with bipolar develop coping mechanisms and deal with mood swings. If medication doesn’t work, there are more avenues that can be explored. ECT (electro-convulsive treatment) has come a long way from the bad old days and the horrors depicted in Cuckoo’s Nest. TMS (transcranial magnetic stimulation) is another kind of therapy that has shown progress in treatment-resistant bipolar disorder. Ketamine infusions are also being studied and tried as a treatment. There are people who find nutrition, mindfulness, exercise, and other techniques helpful, and these can be productive adjuncts to other kinds of treatment.

Bipolar people are violent. People with mental illnesses are more often the victims of violence than perpetrators, despite what you may have seen in the movies, television shows, and even news stories. People are quick to say that any violence is due to mental illness or a person who is “off their meds,” but this is quite often a knee-jerk reaction with a questionable basis in fact. The risk of violence is minimal for bipolar persons unless they are also substance abusers.

Bipolar people can’t have romantic relationships, friends, or families. Relationships may be more difficult with bipolar disorder, as they are for many people with mental illnesses, but they are not impossible. Many families care deeply and support their relatives who have bipolar, and many people who have bipolar have loving relationships, marriages, and families of their own. These relationships may be more difficult than those that non-bipolar people have, but they are not impossible. It is true that family members and friends may not understand mental illness and may reject anyone who has them, but there are also many who will stand by you, help you heal, and even advocate for you. Besides, relationships among the general population are not guaranteed to be long-lasting and trouble-free either!

You may share this post with anyone who believes these myths. Perhaps it will lead them to a more realistic view of bipolar disorder and help them better understand friends and family members who are affected by it.

Not long ago, I noticed that C-SPAN was going to be featuring testimony before Congress on mental health issues and legislation. I thought I’d see what was up. What I heard was a lot of questions about the opioid crisis and what the nation’s response to that ought to be. I tuned out and turned it off. I had been hoping to hear about issues such as insurance parity, access to treatment, assisted outpatient treatment, and more. Instead, what I got was a focus on substance use and abuse.

I also recently saw a map that indicated which states had reimbursement programs for Substance Use Disorders (SUD) and Mental Health initiatives. By far, most of the programs were for SUD. States that covered mental health conditions were in the minority, and most of them provided coverage for both SUD and mental illnesses.

I’m not denying that substance use and abuse are problems in the U.S or that legislative attention needs to be paid to them. I know the opioid crisis is tragically affecting individuals and communities across the country. Nonetheless, I wish as much attention was paid to mental health issues. They affect individuals and communities, too.

I was a little short-sighted as well as impatient, however. The two topics are not mutually exclusive. Mental illness and drug use are often comorbidities (also called co-occurring disorders or dual diagnoses). Still, there are in many places rehab facilities for people who abuse drugs and alcohol, and separate facilities for people with mental illness.

The two conditions share many characteristics. Both can be attributed to brain chemistry. Very Well Mind notes, “[t]he activation of the brain’s reward system is central to problems arising from drug use. The rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.” The effects of brain chemistry on mental illnesses such as depression, bipolar disorder, and schizophrenia are not well understood and are even debated. But though the mechanisms of action on the brain may be different, there is little doubt that the brain is involved in both addiction and mental illness. Medline Plus notes that there are other similarities in causation, including genetics, stress, and trauma.

Various psychiatric disorders are associated with substance use, including psychotic disorder, mood disorders, OCD, sleep disorders, sexual dysfunction, and neurocognitive disorders. Despite this, PubMed has said, “In spite of the high association between substance use and psychiatric disorders, there is a surprising paucity of studies related to treatment and outcome. A few well-designed studies have been recently published and more studies of this nature are required in order to address the challenges posed in the treatment of dual disorders.” One thorough, well-researched article with many sources listed is available from MentalHelp.net.

The latest version of the DSM recognizes the overlapping of substance abuse and mental illness, with substance-related disorders added to the DSM 5. Addiction Policy Forum reports: “The DSM-5 has eleven criteria, or symptoms, for substance use disorders based on decades of research. The DSM-5 has helped change how we think about addictions by not overly focusing on withdrawal.”

The National Alliance on Mental Illness (NAMI) says, “The best treatment for dual diagnosis is integrated intervention, when a person receives care for both their diagnosed mental illness and substance use disorder. The idea that ‘I cannot treat your depression because you are also drinking’ is outdated — current thinking requires both issues be addressed.” They add that the treatment should consist of six elements: inpatient detoxification and inpatient rehabilitation; psychotherapy – especially Cognitive Behavioral Therapy (CBT); medications – including those that assist in detoxification; supportive housing such as group homes; self-help; and support groups, whether faith-based or not.

Of course, the idea that substance use and abuse are diseases has not caught on with many members of the general public. They consider them to be personal failings or the result of having no self-control or hanging around with disreputable friends. Perhaps that is one reason public officials do not listen to those who promote changes in legislation to improve both substance abuse and mental health care. The intersection of addiction and mental health challenges is even more foreign. Advocates who contact their legislators are likely to be brushed off with a “Thank you for contacting my office” letter. Politicians are also disinclined to listen to medical advisors on the subject, especially now that their attention is focused on COVID-19 policy.

Perhaps those who advocate for more enlightened responses to substance use and abuse issues, mental health treatment, and dual diagnoses should start a little lower. Educating legislators is fine, but change is not likely to result until their constituents demand it. For one thing, advocates for reform could attend local city or county meetings in order to counter the pervasive NIMBY (Not In My Back Yard) response to treatment facilities. They could also educate their family members and friends about the realities of drug use, mental illness, and the intersection between them. When more people understand these ideas, they may be more likely to support legislative approaches that encompass them.

Grassroots efforts such as Mothers Against Drunk Drivers (MADD) have worked in the past to contribute to societal change and legislation regarding that problem. It may take a similar effort to achieve change in how addiction and mental illness are understood and treated.

I still think the Congressperson wasn’t talking about dual diagnoses, though.