Akathisia is a clinical term for extreme inner restlessness. People who are experiencing akathisia have great difficulty sitting still, or maybe even sitting at all. I first experienced akathisia on Abilify (which I ultimately discontinued because it gave me a facial dyskinesia), and it continued to plague me as I tried different antipsychotics, such as Haldol. I found myself unable to do anything except to go outside, pacing back and forth and smoking cigarettes. Propranolol offered me some relief from the worst of it, but the effect eventually faded.
The medications that are most likely to cause extrapyramidal side effects (EPS) — including tardive dyskinesia — are also the most likely suspects for akathisia. In fact, you might even say akathisia is a type of EPS, even though it does not cause per se involuntary movements. Common suspects would include Haldol and probably also Abilify, which has much greater risk of EPS than we once believed.
It’s excruciating to live with akathisia, and yet most people have never even heard the term. A common descriptor is the feeling of “wanting to crawl out of your skin”.
I’ve had some trouble over the years differentiating between akathisia and hyperactivity associated with my ADHD. The main difference between these two scenarios is the cause, but when you’re on a regimen of multiple antipsychotics plus lithium plus stimulants plus benzodiazepines it becomes difficult to discern cause and effect. No doubt in my mind, at its worst akathisia feels worse and even more frustrating than ADHD — but what about those days where it’s just kind of there?
I’ve also experienced restless leg syndrome. Some scholars believe there is a link between RLS and akathisia — essentially, that akathisia is like RLS experienced during the day (as well as at night — akathisia has kept me awake many nights). I would say this is a pretty apt comparison.
RLS and akathisia may be related.
When I first started propranolol, and was able to sit and rest for a few minutes for the first time in weeks. It was like getting your first pair of glasses, and realizing you can see clearly now. The relief was nearly immediate. Unfortunately, it faded somewhat over time. But I’ll remember that instant where it hit me, the moment I put on the glasses, forever. I hadn’t even realized how bad it was until then.
Traditionally, it has been thought that bipolar disorder emerges most typically in the early to mid 20s of a person’s life. It has been known since the time of Emil Kraepelin (circa 1921), however, that children can be affected by this illness. While adolescent onset (mid-to-late teens) is now recognized as common and similar to the presentation of adult bipolar disorder, pediatric onset bipolar disorder remains the subject of debate, and its presentation is somewhat different than adult bipolar disorder.
Why do some children get bipolar disorder?
We do have some idea why some people get bipolar disorder as adults, and others get it much younger. The effect is known as genetic anticipation, which occurs when certain genes accumulate in later generations. We know that bipolar youth are highly likely to have members of their family belonging to previous generations (parents, grandparents, aunts, uncles) with bipolar disorder. When those genes add up over successive generations, and the person has a LOT of the polymorphisms that cause bipolar disorder, they tend to get it a) younger and b) more severely. This also helps to explain why pediatric onset bipolar tends to be a clinically severe manifestation.
There is often a long delay between onset of symptoms and treatment. For me, it was 8 years (possibly more).
How does pediatric-onset differ from adult bipolar disorder?
Pediatric onset bipolar is commonly characterized by very rapid cycling. This is an uncommon phenotype (what the disorder “looks like”) in adults, but the majority of children with bipolar disorder are rapid cyclers. Chronic irritability is also common and is part of the reason pediatric bipolar disorder is so controversial. An episodic pattern of moods — whether the manias are dysphoric or euphoric — is arguably the hallmark of bipolar disorder; chronic irritability doesn’t seem to fit the bill, and in children who do not experience depression, an alternative diagnosis may be more appropriate. Nonetheless, irritability is a common symptom even among those children who seem to clearly meet the criteria for bipolar disorder.
Rapid cycling is the rule rather than the exception in children.
In my anecdotal experience (my symptoms started before the age of 10) I still have rapid cycling and dysphoric mixed manias as an adult. I urge those who are doubtful that rapid cycling bipolar is “real” or that it is somehow less valid to consider that many adults with this phenotype first experienced bipolar symptoms as children.
Recommended reading about bipolar in children
If you want to learn more about bipolar disorder in kids, I recommend the book The Bipolar Child by Demitri Papolos. It is really informative and helped me to better understand myself, as someone who had pediatric onset. I sat down in a library and read it all within a couple of hours.
I’m medication resistant, meaning that meds don’t fully stabilize my cycling. I’ll never be the person who can say “nobody even knows I am bipolar”. In fact, I have to disclose my bipolar disorder to most of the people I work with, due to how it impacts my working hours.
I’ve tried every atypical antipsychotic approved for use in psychiatric patients in the United States except for clozapine (although that has been on the table) plus two typical antipsychotics, three anticonvulsant mood stabilizers, and many other drugs including benzodiazepines, antidepressants, hypnotics, lithium, and so on. I’ve taken the tour.
Currently, this is my regimen: olanzapine, risperidone, lithium, diazepam, and amphetamine salts. I continue to experience symptoms, even with all of that on board. So how do I live and continue to work? The answer is not one-size-fits-all, but for me there are a few key components.
1. Consistent sleep times
I try to go to sleep at the same time every night, and wake up at the same time every morning. Of course it doesn’t always work out that way, but I try. I also make sure not to schedule any meetings that are too late at night, and not to stay out too far into the evening, as both of these things will keep me awake. Each person’s natural bedtime is different, so I can’t tell you what time is correct for you, but for me it’s usually between 10 PM and 12 AM (a fairly wide window, I know).
Sleep is super important in managing bipolar disorder.
2. Structure during the day
It helps me if I am able to maintain some regularity and consistency throughout my days. Since I’m an academic and my work schedule is flexible, this is something I largely have to impose on myself. When I’m really struggling I’ll schedule events in my Google Calendar, even for things I don’t “have” to do — recreational activities, like video games or watching anime. The point is to stay busy, but not too busy. Make sure to build in plenty of breaks. This also helps me get the things on my to-do list for work done efficiently.
I use Google Calendar for this.
3. Take meds religiously
This one doesn’t need a whole lot of explanation, but it’s an important point. Don’t stop taking your meds. At least for me, it always ends in hospitalization, and that’s a huge disruption to my life even though I’m quite used to it by now. Don’t get me wrong — sometimes hospitalization is necessary. However, it’s best to avoid it as much as possible, so that I can stay in contact with my friends and family.
Medication is the primary treatment for bipolar disorder, and it must be taken regularly.
4. Light and darkness
Research has shown that light/dark cycles have a dramatic impact on bipolar moods. I use a light box (or “sun lamp”) for a couple hours daily in the winter. You can buy a clinical strength sun lamp on Amazon (I am not affiliated, and do not gain anything from this) but be aware that the market is flooded with lamps that are not full clinical strength. The recommended protocol for bipolar disorder is to start at noon for 10 minutes, then add 10 minutes every day until you reach 1 hour. This is because the sun lamp does run some risk of triggering mania. At the same time, when you go to sleep (or ideally, when it’s naturally dark outside) there is an equivalent if not more important factor: darkness. Total darkness at night has been shown to dramatically stabilize patients who did not respond to conventional treatments.
Sun lamps can help with low mood and low energy.
5. Mindfulness and psychoeducation
The point of mindfulness in this context is to be able to recognize what mood state you’re in. Likewise, it helps me to be as educated as possible. I read tons of papers, but these are not super accessible to everyone; if you trust your psychiatrist, I recommend asking lots and lots of questions so that you can understand as much as possible. I also compiled a list of some of my favorite bipolar books. The insight into what you’re going through can save your life, even if it doesn’t change what you’re going through.
Keeping track of your mood takes time and practice, but it can be a huge advantage in managing bipolar disorder.
Ah, lithium; it’s been our gold-standard treatment for bipolar disorder for many years, and can work for people who have failed other drug trials. It is also one of the only drugs known to decrease the risk of suicide1. But how does it work?
It’s a bit more complicated to understand than, for example, an SSRI (which, ultimately, increases serotonin in the synapse, through a fairly intelligible mechanism of stopping reuptake). Despite knowing since 1949 that lithium was an effective treatment for bipolar disorder, we still don’t fully understand its mechanism of action.
There are a lot of signalling pathways in the brain.
One of the difficulties in determining this is that lithium goes everywhere in your body. Within the brain, it can cause an absurd number of changes through numerous signalling pathways. Like other drugs, it can cross the brain-blood barrier (an important quality for psychiatric medications, since they target the brain) but, uniquely among psych meds, it can also enter your intracellular space — hiding inside your cells, instead of just floating around in your blood.
It is excreted by the kidneys in urine, although it is also known to be excreted in human sweat and tears2. (I’ve had hyper-salty tears caused by lithium every so often.)
Lithium appears to increase the concentration of some neurotransmitters (potentially serotonin and GABA) while moderating the effects of dopamine and norepinephrine through its effects on voltage-gated channels3. This action causes a broad cascade of effects throughout the entire brain that restores balance in people with bipolar disorder. Lithium can get into any cell in your body, and it goes inside your neurons (brain cells) too. This is how it affects voltage-gated channels and moderates the activity of all neurotransmitters.
Although we usually call it a mood stabilizer, it’s not related to any other drug we put in this class, since it is not an anticonvulsant. Lithium is probably most accurately classified as a neuroprotective drug4, like memantine (a drug typically used for Alzheimer’s disease). There is even some speculation that memantine could augment the effect of lithium, due to its similar mechanism of action, but specific to the NMDA receptors.
A key point to understanding the pharmacodynamics of lithium is that lithium, in the human body, can use the same transporters as sodium. It fits where sodium should go — therefore, it exits cells through active transport systems designed for sodium, but at about half the speed of sodium. The similarity of lithium and sodium explains why lithium is excreted by the kidneys and not metabolized by the liver.
a) lithium salts; b) sodium salts
This is also why activated charcoal will not absorb lithium. Your body sees it as a metallic salt (it has a positive charge), and metals (or charged ions) are not attracted to charcoal. In addition, the similarity of sodium and lithium creates a sort of sodium-lithium ecosystem in your body; if you maintain a steady dose of lithium but drastically reduce your intake of sodium, your lithium levels can rise to toxicity.
References
Kessing, L. V., Søndergård, L., Kvist, K., & Andersen, P. K. (2005). Suicide risk in patients treated with lithium. Archives of General Psychiatry, 62(8), 860–866. https://doi.org/10.1001/archpsyc.62.8.860
Fraunfelder, F. T., Fraunfelder, F. W., & Jefferson, J. W. (1992). The effects of lithium on the human visual system. Cutaneous and Ocular Toxicology, 11(2), 97–169. https://doi.org/10.3109/15569529209042704
Lenox, Robert H., H. C.-G. (2000). Overview of the Mechanism of Action of Lithium in the Brain: Fifty-Year Update. 61.
Gray, J. D., & Mcewen, B. S. (2013). Lithium’s role in neural plasticity and its implications for mood disorders. Acta Psychiatrica Scandinavica, 128(5), 347–361. https://doi.org/10.1111/acps.12139
I am bipolar type 1. 🎭 That is the most severe form of bipolar disorder. (Bipolar 2 can have very severe depression, but because it doesn’t have severe mania it doesn’t progress along the same course. Something like that.) I’ve been inpatient 18 times, and I’ve been discharged from the ER a few additional times as well.
Interestingly, I don’t have what most people would think of if you said “classic bipolar disorder”. I have mostly dysphoric manias (and sometimes euphoric hypomania), so no grandiose delusions or belief that I can see the flow of energy that connects all things. Just bugs that… may or may not be real. 🐜 But, the dysphoric mania type is actually sliiiiiightly more common than euphoric (feel-good) mania in real-world bipolar 1 people, according to one study1.
The main reason my bipolar is unusual is that it is so FAST. My psychiatrist describes it as “brittle” — a medical term often applied to highly unstable diabetes patients, where blood sugar skyrockets but then drops with intervention but then skyrockets again. It follows the same kind of course.
Blood sugar in brittle diabetes
Usually, I think my cycle (including both mania, which almost always comes first for me, and then depression — most bipolar people have one type of episode almost always come first, but it’s a 50/50 split which one2) is 2 to 4 weeks long. If it’s a lot faster than that it’s considered a mixed episode.
I rarely ever have euthymic (normal mood) periods and I don’t have any asymptomatic periods. (I have persistent problems with memory and executive functioning and other stuff.)
💊 Currently every day I take: lithium, Thorazine (chlorpromazine), Zyprexa (olanzapine), Valium (diazepam), and Adderall (amphetamine salts). 💊
What causes bipolar disorder?
A lot of research links bipolar disorder to various things: a) circadian instability, sleep problems ⏰ b) inflammatory processes in the brain 🔥 c) epilepsy 📈 — they have a lot in common, and medications used to treat epilepsy are often used to treat bipolar disorder; I think you can think of bipolar as being similar to some kind of epileptogenic brain activity but on a more macro scale. Similarities to Temporal Lobe Epilepsy include age of onset and genetic cause among other things and they do have a very very high comorbidity rate. d) genetics 🧬 — 97% of bipolar disorder is explained by genetic variance alone and it is more heritable than autism or schizophrenia (I believe it might be the most heritable psychiatric disorder in DSM-5)
Most people get bipolar disorders in their 20s, but I got it early. I had suicidal depression sometime before the age of 10 and had my first clear hypomanic episode when I was 16. My parents were anti-psychiatry, so I wasn’t in treatment until I went to college and I almost became an emancipated minor because I was still 17 and it was that serious 🙃
Unlike autism, which is a fairly new concept (although autistic people have almost certainly existed for thousands of years) bipolar disorder is a very old idea for a distinct illness that occurs in all cultures that I know of. Other English names for it have been “manic depression” (a term I actually prefer), “manic-depressive psychosis”, “circular insanity” 🔁, all referring to a highly organized and unusually patterned occurrence of severe disturbances in mood.
That’s actually what I study now in my PhD program! I’m looking for patterns in bipolar disorder. I’m very good at patterns 🧩
References
1. Grant BF, Stinson FS, Hasin DS, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2005;66(10):1205-1215. doi:10.4088/JCP.v66n1001
2. Koukopoulos A, Reginaldi D, Tondo L, Visioli C, Baldessarini RJ. Course sequences in bipolar disorder: Depressions preceding or following manias or hypomanias. J Affect Disord. 2013;151(1):105-110. doi:10.1016/j.jad.2013.05.059
Recently, on Twitter, I confessed that I had not been able to complete reading NeuroTribes (a very interesting book, and also a lengthy one). The other person insisted that a PhD student should be able to read a book and accused me of lacking academic integrity — basically, that I am lazy and don’t deserve my PhD.
I’m here to say that attitude is inherently ableist. But to give the benefit of the doubt, perhaps most people don’t know that bipolar disorder actually can affect your ability to read. I learned to read early as a child — I was a prolific consumer of text, and I had a college reading level in elementary school (this is called hyperlexia). But after being medicated for bipolar disorder, my ability to sustain focus and momentum while reading a long document has been very limited.
Lithium is probably the biggest offender. It kind of affects how you see words on the page — like a pseudo-dyslexia, the words seem kind of blurry and distorted. It can be impossible to read full books. I can still read journal articles because they generally have a defined structure and an abstract. I can also read poetry, which I enjoy. I recommend seeking out these kinds of texts if reading is something you struggle with.
Most of all, I want you to know that this is common, you are not alone in having an acquired inability to read and you still deserve your career, whatever that may be. It’s not a matter of “intellectual thoroughness”; it’s part of a disability, and it’s more common than you think.
I also find it difficult to watch videos, TV, or movies. The information conveyed through video media covers many modalities — sound (music), speech, visuals, movement (spatial), and the overall plot you’re supposed to be following. Sitting for the length of a movie is hard, but it’s also just hard to follow so many things at once. My brain gets overwhelmed with too much information of different kinds to process (evidence of poor sensory integration, a symptom of autism). But it helps to reduce the overload by using captions (combining speech with visuals, thus reducing the number of information modalities) or watching something animated, which compresses the demands of visual and spatial information greatly.
Recently, The Mighty published an article about the differences between anxiety and hypomania. However, I wanted to complicate the discussion by bringing up something that breaks the juxtaposition of anxiety and mania: primarily anxious mania, which is most likely a mixed episode associated with bipolar type 1.
The author describes how her anxiety leaves her “immobilized”. This can actually happen in mania, too — but usually not in hypomania. Hypomania is often very productive. Full mania is no longer productive — it’s frantic, potentially confused, and may be characterized by manic stupor. Emil Kraepelin used this term to describe a flight of ideas and elevated mood (not necessarily happy, but revved-up) combined with psychomotor slowness or immobility. I’ve been in this state, and I experienced it subjectively as intense feelings of anxiety paralyzing my every move. This might also be referred to nowadays as catatonia, and something similar can occur in severe depressive states; however, the catatonia that coincides with mania is likely excited catatonia (characterized by purposeless movements rather than being completely still).
Hypomania isn’t rare, exotic, or exciting to me. It’s just part of my life, and I take advantage of it when it comes around — which it will, no matter what. But, to me, full mania is to be avoided. Anxiety is also a daily part of my life, but the anxiety and paranoia I experience during a manic episode is even more excruciating than it usually is. Juxtaposing them as discrete, separate states can only take you so far in understanding what mania is and how it affects people.
There’s no doubt in my mind that Van Gogh had bipolar disorder. He had many symptoms related to bipolar disorder: manic episodes, depressive episodes, hallucinations, sleep disturbance, substance abuse, memory problems, nightmares, and anxiety, to name a few from his asylum files.
Yet, additional diagnostic labels could help to clarify his overall presentation. One diagnosis that has been put forward is BPD. It does seem to explain some of the events of his life, for example, his heated interpersonal conflicts and fears of abandonment related to Paul Gauguin. However, a diagnosis of autism has not been seriously considered. This is interesting in light of the heightened prevalence of bipolar disorder in autism — an autistic person is as much as 8.5 times more likely to have bipolar disorder than a non-autistic person (this number assumes no intellectual disability and a diagnosis before age 28).1 Another study found that 7% of autistic people also had bipolar disorder.2
As a child Van Gogh was described by his younger sister as “intensely serious and uncommunicative, and walked around clumsily as if in a daze, with his head hung low”, and went on to say that he was like a stranger both to his siblings and to himself. A servant said he was “an odd, aloof child who had queer manners and seemed more like an old man” than a child.3 These are characteristics often ascribed to some autistic children, even poor motor coordination (dyspraxia).
Vincent was deeply intelligent, thoughtful, and demonstrated what seemed like the capacity to be successful, but as a young man he struggled to find a vocation that could accommodate him. He drifted from an art dealership (where he was fired for arguing with buyers), to a teaching job, to a minister’s assistant for a Methodist church, to a bookshop where he reportedly doodled and translated parts of the Bible into English, French, and German, to religious studies. He failed his entrance exam in theology and his missionary course. Religion was a special interest for Van Gogh. He was endlessly devoted and passionate about the subject, but his odd behavior made him an ineffective preacher, and he was not a good student.
Van Gogh had severe social problems which seem to have started early in his life. People repeatedly thought that he was odd, and they didn’t want to be around him. His peculiarities were off-putting. Children were scared of him. Scholars suggest that he did not understand the concepts of diplomacy or salesmanship, that he lacked insight into the thought processes of others, and lacked the ability to cognitively understand their emotions and motivations.3 He was emotionally dysregulated and prone to agitated or impulsive meltdown behaviors. As his interest in painting became more intense and all-consuming, he neglected maintenance of his body or appearance, appearing even more eccentric.
One of the highlights of Van Gogh’s medical files that has yet to be parsimoniously explained is his chronic stomach issues. In particular, gastrointestinal problems seem to be an important feature of autism4 although bipolar disorder may also be related to stomach problems.
Vincent van Gogh (Dutch, 1853 – 1890 ), Green Wheat Fields, Auvers, 1890, oil on canvas, Collection of Mr. and Mrs. Paul Mellon
Finally, there’s the most obvious trait of Van Gogh’s: his artistic ability. Many people have suggested that Vincent might have had some form of synesthesia. Further, I hypothesize that hue discrimination may, like pitch discrimination, be enhanced in some autistic people.5
A diagnosis of autism didn’t exist in Van Gogh’s time — in fact, wouldn’t exist for over 50 years after his death. Perhaps it’s not so surprising that the autism connection has been overlooked. Vincent van Gogh’s wild, reckless nature combined with intellectual and artistic sensibilities (and lack of mathematical talent) defies narrow stereotypes of autism, yet embodies a certain reality of it: he was thoughtful yet lacked insight, seen as a stranger by the world around him while experiencing the world as fundamentally strange, and possessed incredible gifts yet was understood as deficient. Maybe it’s time to look beyond famous scientists and mathematicians for autistic historical figures.
References
1. Selten J-P, Lundberg M, Rai D, Magnusson C. Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder: A population-based study. JAMA Psychiatry. 2015;72(5):483-489. doi:10.1001/jamapsychiatry.2014.3059
2. Skokauskas N, Frodl T. Overlap between autism spectrum disorder and bipolar affective disorder. Psychopathology. 2015;48(4):209-216. doi:10.1159/000435787
4. Adams JB, Johansen LJ, Powell LD, Quig D, Rubin RA. Gastrointestinal flora and gastrointestinal status in children with autism – comparisons to typical children and correlation with autism severity. BMC Gastroenterol. 2011;11. doi:10.1186/1471-230X-11-22
5. Heaton P, Williams K, Cummins O, Happé F. Autism and pitch processing splinter skills: A group and subgroup analysis. Autism. 2008;12(2):203-219. doi:10.1177/1362361307085270
For me, mixed episodes are the worst part of my bipolar disorder. It’s hard for people without bipolar disorder to comprehend how it could be that you feel mania and depression at the same time. It doesn’t have to be simultaneous, per se — it could just be very quickly alternating — but for me it is, at times, simultaneous.
In actuality, mixed episodes aren’t rare. The most common presentation of bipolar 1 disorder is a combination of depression and mixed episodes (32%), followed by the combination of depression and manic episodes (30%; Grant et al., 2005). Mixed episodes are also common in bipolar 2 disorder (Benazzi et al., 2004) although, understandably, these tend more towards the depression side.
To understand my own mixed episodes, I draw a distinction between physical and mental energy. Mania typically involves high levels of both physical and mental energy: you feel physically great, you never seem to get tired, and your thoughts and ideas might be racing around in your head. In contrast, depression involves low physical and mental energy: you’re tired and sluggish, you might be in pain, and your thoughts feel jammed like a printer that just won’t print.
Your brain on depression.
My own mixed episodes tend to feature low physical energy and high mental energy. I can’t sleep at night because my thoughts keep me awake, but instead of feeling ready to go in the morning, I feel tired and miserable. I may pace around because of all the energy inside my head, but my body aches constantly. I tend to become very preoccupied with suicide. Mixed episodes are the most dangerous time for me.
I also might have hallucinations during mixed episodes, and they’re distinctly unpleasant. One that recurs for me is the bugs. I start out by feeling them crawling on my skin, particularly when I lie down in bed to try and sleep at night. No matter how many times I meticulously check my pillow, I can’t find any bugs, but I know they’re there (and know they’re not there — simultaneously). At times, though, this has progressed further to actually seeing bugs everywhere around my apartment, and not being able to tell which are real and which are imagined (because there probably were some real bugs). I once came to the conclusion that not all of the bugs could be real because there were simply too many different species living in my studio apartment. On another occasion, I heard voices mocking me from inside my dishwasher.
Other times, I acquire some delusional or near-delusional beliefs. I have been absolutely convicted that I had AIDS in one instance, Parkinson’s disease in another. I don’t have either of these diseases, but I couldn’t be dissuaded from my belief, at least in the moment. When I believed I had AIDS, I even started writing goodbye letters.
Though I’ve never departed too far from reality, personally — just wandered a little bit astray. I’ve been underwater, but always close enough to see the light on the surface. Some people experience psychosis in a much more encompassing way. Hallucinations and delusions can be truly terrifying, even life-changing experiences. Mine seem a bit mundane in comparison. No angels, no demons… just bugs.
To my horror, I’ve probably seen most of these at some point.
One could also envision a mixed episode with high physical energy and low mental energy. This might result in a kind of catatonic state, probably an agitated catatonia. This is considered a very dangerous state in its own right because catatonic patients are less than fully conscious of their actions, and if they are very agitated, they could pose a risk to themselves and others around them.
Do you have mixed episodes? How do you understand them?
Benazzi, F. (2007). Bipolar disorder — focus on bipolar II disorder and mixed Benazzi, F., Koukopoulos, A., & Akiskal, H. S. (2004). Toward a validation of a new definition of agitated depression as a bipolar mixed state (mixed depression). European Psychiatry, 19(2), 85–90. https://doi.org/10.1016/j.eurpsy.2003.09.008
Grant, B. F., Stinson, F. S., Hasin, D. S., Dawson, D. A., Chou, S. P., Ruan, W. J., & Huang, B. (2005). Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66(10), 1205–1215. https://doi.org/10.4088/JCP.v66n1001
People with bipolar disorder commonly have memory problems. This is actually something I’ve been doing research about as a PhD student at UCLA. Not only that, it’s something I struggle with myself.
There are two main categories of memory problems in bipolar disorder: problems that are associated with a mood episode, and problems that exist outside of mood episodes (during euthymia, or well periods).
During episodes of depression, problems with explicit memory are common. That’s the kind of memory you’re using when you try to recall facts or events — in contrast to implicit memory, which includes emotional learning (conditioning) and procedural learning (like learning how to ride a bicycle). Implicit memory tends to be preserved, but depressed people struggle to explicitly remember things. For example, trying to remember the names of past presidents might become extremely effortful. This is actually the same for unipolar depressives. Controlling for the severity of depression symptoms, bipolar and unipolar depressives are very similar in the area of memory performance (Bearden et al., 2006).
Multiplication tables might be very difficult for a depressed person to recall
Memory impairments are more pervasive in manic episodes. Research has found that during a manic episode, people perform more poorly at tasks requiring episodic memory (the kind of memory you use when you remember a scene you’ve lived through, typically from a first-person perspective), working memory, spatial attention, and problem solving (Sweeney et al., 2000). Many people who have experienced manic episodes have a great deal of difficulty remembering what happened during the episode. It’s possible that mania disrupts the encoding of new memories (King et al., 2013). For some of us, this is a double-edged sword: it’s painful to remember, and yet it’s painful not to remember. Sometimes we’re left trying to piece together what actually happened while simultaneously part of us is trying to move on from it. Even worse, sometimes other people remember better than you do.
Problems with episodic memory aren’t limited to mania, though.
Various studies have shown bipolar people who are euthymic (not currently having a mood episode) to perform poorly at memory-related tasks. Problems with executive functioning frequently come up — these problems can be similar to people with ADHD. But one of the most noteworthy findings is impairment in episodic memory about one’s own life. In particular, it seems like memory for specific events is impaired, but memory for personal facts (like one’s name or birthday) are not affected (Shimizu et al., 2009).
It’s hard for me to remember a lot of things I’ve lived through. Not infrequently I meet people who tell me we’ve met before, but I have no idea who they are. I have friends that I don’t remember how or where we met. Even memories I’d like to keep seem not to stick very well, which is saddening. I forget most of what happens after a year or two. Sometimes the things I do remember are a little strange. According to my psychiatrist, I have an incredible ability to know exactly how many times she’s told me the same story in the past, but I don’t remember the contexts I heard it in.
I feel like my psychiatrist would relate to this
One study (King et al., 2013) found that when they asked bipolar disorder patients to recall memories from their life, they were more likely to recall those memories from a third-person or observer perspective. It makes me wonder why that is. It’s like the people with bipolar disorder can’t remember being in their own head, even if they can “see” what happened in their memory. Something is disconnected between their past and present minds. They specifically can’t remember being themselves.
Bipolar disorder can be so much more than having emotional “ups” and “downs”. For some people bipolar disorder affects us every day and changes how we live life. Many people don’t realize how memory problems can affect us. When I write, I write about the present at least as much as I write about the past, because I know how transient the present really is.
Have you ever experienced something like this?
Bearden, C. E., Glahn, D. C., Monkul, E. S., Barrett, J., Najt, P., Villarreal, V., & Soares, J. C. (2006). Patterns of memory impairment in bipolar disorder and unipolar major depression. Psychiatry Research, 142(2–3), 139–150. https://doi.org/10.1016/j.psychres.2005.08.010
King, M. J., Macdougall, A. G., Ferris, S., Herdman, K. A., Bielak, T., Smith, J. R. V, … Mckinnon, M. C. (2013). Impaired episodic memory for events encoded during mania in patients with bipolar disorder. Psychiatry Research, 205(3), 213–219. https://doi.org/10.1016/j.psychres.2012.08.005
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