Was Vincent van Gogh autistic?

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

3. Butterfield, B. The Troubled Life of Vincent Van Gogh. Vincent van Gogh website. September 21, 2002. Accessed May 24, 2020.
http://www.geocities.com/Paris/Louvre/9633/VincentVanGogh.htm

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


What do mixed episodes feel like?

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


Memory in bipolar disorder

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

Shimizu, M., Kubota, Y., Mason, R., Baba, H., Calabrese, J. R., & Toichi, M. (2009). Selective Deficit of Autobiographical Incident Memory in Subjects with Bipolar Disorder. Psychopathology, 42, 318–324. https://doi.org/10.1159/000232974

Sweeney, J. A., Kmiec, J. A., & Kupfer, D. J. (2000). Neuropsychologic impairments in bipolar and unipolar mood disorders on the CANTAB neurocognitive battery. Biological Psychiatry, 48(7), 674–684. https://doi.org/10.1016/S0006-3223(00)00910-0


My medication history

I have a long and arduous history with medications. Sometimes, it takes quite some time to strike the right balance with meds and bipolar disorder. This is my own personal review of each medication I’ve been on. There’s a lot! My reviews won’t necessarily be applicable to other people because each person’s response to a medication is different, but hopefully this provides some sense of just how many trials it can take to find something that works.

Stimulants

Adderall — amphetamine salts, a classic stimulant drug. Adderall XR is an extended-release preparation. For some reason the XR didn’t work well for me. I still take the IR daily.

Ritalin — methylphenidate, a different stimulant drug. It has important differences from Adderall and may work better in some people. Slightly different forms of Ritalin go by other names, such as Focalin.

Vyvanse — basically a different kind of Adderall XR,; it is the same molecule as Adderall with an extra group attached that renders it inert, which is then cleaved in the liver over time to release Adderall. To me it feels less effective than Adderall, doses held equivalent.

Mood Stabilizers / Anticonvulsants

Lithium — I’ve taken doses ranging from low to high (currently I take a high dose). Lithium dose is measured by the concentration of it in your blood; the highest dose varies depending on individual differences. You do get frequent blood tests while the ideal dose is being determined, and less after that. It is incredibly effective for many people. Because I’m on a high dose, it sometimes makes me nauseous or makes me throw up, and my hands tremor quite a bit. The cognitive side effects are the worst, but they get better over time. 

Lamictal — lamotrigine. For some people with bipolar disorder, lamotrigine is a better drug than lithium. It is not strongly anti-manic (unlike lithium), but for some this may not be a problem; however, it may be superior at treating bipolar depression. Rarely, it can cause a horrifying skin reaction when you first start taking it (and for that reason, titration takes forever — for me, I believe it took 5 weeks to reach 200mg). Past that initial window, it is considered to have very few side effects.

Depakote — valproic acid. It’s more anti-manic than lamotrigine. It smells terrible, yet apparently it comes in a form designed to put in a patient’s food which psychiatrists call “Depakote sprinkles”.

Gabapentin — I took it for anxiety, and it did put me in a good mood, so I suppose it worked.

Antipsychotics

Seroquel — quetiapine. People pronounce it in wildly different ways, I say “kweh-tie-ah-peen”. It helped with my mixed episode, but eventually it lost effectiveness and I found myself staying awake all night on 800mg (that’s a lot of Seroquel). Basically, it’s good for putting you the fuck to sleep, or at least it should be.

Zyprexa — olanzapine. It made me gain a lot of weight. It was fairly effective, but I had to discontinue it due to problems with my liver and its effect on my metabolism. It’s also pretty good at putting you to sleep. I preferred the sublingual form during my inpatient stays (it’s vaguely citrus flavored) because it made me feel better really quickly when I was agitated.

Abilify — aripiprazole. This drug actually helped me for a long time, and it still seems to have some effectiveness but I developed a facial dyskinesia while taking it. That’s an involuntary muscle movement, in my case of my lower left face. This was thought to be uncommon at first, but it turns out with long-term Abilify use (4 years for me), it’s quite possible. I can’t take any drugs related to Abilify anymore — these include Vraylar (cariprazine) and Rexulti (brexpiprazole). Abilify is not usually good at putting you to sleep, but when I started taking it I was on a dose that was too high for me at the time and I was very somnolent most of the time. 

Geodon — ziprasidone. I felt well but it made me throw up a lot. I discontinued it and got some Zofran from the ER. You have to take it multiple times per day, so you hope it doesn’t put you to sleep. I usually did have to take a mid-day nap.

Latuda — lurasidone. You have to be sure to take it with food. It wasn’t very effective for me. 

Saphris — asenapine. Warning, it only comes in a sublingual form and it’s cherry flavored. Nope. I only took it once and I had nightmares about cherry flavor afterwards.

Clozapine — I didn’t actually take this one, but it was on the table. I chose Haldol instead. It is probably considered the most powerful antipsychotic because it has been shown to break through where other antipsychotics have failed, and it was the first “second-generation” or “atypical” antipsychotic. However, it is quite possibly the single most dangerous drug in psychiatry — the potential side effects include a catastrophic loss of white blood cells, among other serious effects. It’s a “drug of last resort”.

Haldol — haloperidol. Haldol is an older drug, one of the “first generation” or “typical” antipsychotics and it is the most potent among those, also with the highest likelihood to cause dyskinesias (including tardive dyskinesia, which is permanent). These side effects have led to the popularity of the “atypical” drugs listed above, which are less likely to cause dyskinesia. Haldol is very effective for me, and I don’t find it sedating at all (which is a blessing and a curse). Having taken most of the atypicals available in the US (except for clozapine, paliperidone, risperidone, and a couple others that are much more rare), I was surprised at how not sedating it is.

Thorazine — I haven’t taken this one either, but it’s been on the table because of its more favorable side effect profile. It is the original antipsychotic drug, from which tricyclic antidepressants were also derived. It has more action on the histamine receptors than Haldol, making it much more sedating. However, this also makes it less prone to cause troubling dyskinesias — for example, antihistamines are actually a treatment for dyskinesia.

Antidepressants

Prozac — fluoxetine. It’s pretty much the basic SSRI. It didn’t do much for my mood at the time. It’s often used in combination with olanzapine/Zyprexa.

Lexapro — escitalopram. It’s an SSRI, and it has high selectivity to affect serotonin reuptake and not norepinephrine reuptake, in contrast to Prozac (which is not very selective). I took it for anxiety and OCD symptoms; I wasn’t convinced it was effective. It also changed my sexual functioning for the worse. 

Wellbutrin — bupropion. It’s an atypical antidepressant that affects norepinephrine and dopamine uptake. I took it to help with smoking cessation. It did make cigarettes taste bad, but I continued smoking them and within short order the drug made me manic.

Trazodone — an atypical antidepressant and an oldie but goodie. This one puts me to sleep (most of the time), and thank God for that.

Remeron — mirtazapine. Another atypical antidepressant. Usually a sleep drug, sometimes used for straight depression, also a great anti-emetic (anti-nausea drug).

Benzodiazepines

Xanax — the only time I took Xanax was recreationally, but I didn’t feel very enamored with the experience. Xanax is highly addictive, I suppose some people find it euphoric in a way. 

Ativan — it’s like toned-down Xanax, it is quite effective but it’s not as euphoric. It has helped me in ways other drugs couldn’t, although whether I would recommend them would be situational due to the addictive potential.

Valium — I’ve only gotten it in the ER, but it lasts longer than Ativan.

Others

Propranolol — a beta blocker, it helps me with akathisia (a side effect of antipsychotics).

Cogentin — benztropine. An antichonlinergic drug used to treat the side effects of antipsychotics. I didn’t take it for very long.


Best books for people diagnosed with bipolar disorder

When I was first diagnosed with bipolar disorder, my therapist gave me a book that changed my life. Books can influence how you understand your own bipolar disorder, and yourself in relation to it. I haven’t read every single book out there, but here are a few that I have read.

Welcome to the Jungle by Hilary Smith

Technically, this is a self-help book. It contains a lot of good information, tips, and recommendations. The thing I like about this book in particular is its humorous and lighthearted style. I read the original edition of this book, and I no longer have it because I gave it to someone else, but I still remember some of the bipolar jokes! I recommend this book to anyone who has just been diagnosed with bipolar disorder but doesn’t know much about it, and needs a source of information.

Manic by Terri Cheney

Manic is a memoir. Memoir can be so helpful, in my opinion, because it allows us to have insight into the lives of people who have faced similar struggles as us. This book describes itself as “visceral” — focused on the experience of mania and depression from a very subjective viewpoint. Cheney herself said the focus is “on what bipolar disorder felt like inside my own body”. Paradoxically, it becomes very relatable by just how idiosyncratic it is. I recommend this book to anyone who feels alone in their struggles with bipolar disorder.

An Unquiet Mind by Kay Redfield Jamison

This is the book that changed my life. As a freshman in college, it single-handedly inspired me to pursue a career in research, and specifically bipolar disorder — which is now my career. Jamison is an authority on bipolar disorder, but this book is not a textbook — it’s a memoir. In a display of great vulnerability (at the time, nobody could know if this book would end her career) Jamison tells the story of her life, from childhood to a breakdown shortly after completing graduate school, mania, psychosis, depression, and a serious suicide attempt. Throughout it all, Jamison interjects wisdom and knowledge. This book simultaneously provides both deep information about bipolar disorder and a revealing look into the life of somebody who lives with it. I would recommend it to anyone who with a curious mindset, who wants to know more about the science of bipolar disorder and the culture of academic psychiatry, as well as the personal experience of living with bipolar disorder from the perspective of an expert.

Have you read any good books about bipolar disorder? Feel free to leave a comment!


Should I be afraid to take lithium?

Lithium has a reputation. When I was first prescribed it, I felt a sense of fear and also — somehow — a sense of achievement, like I had won the lottery for crazy. When you hear about lithium, it’s often to stress that it is only for those top shelf mental illnesses; and it is good for that, however, it’s not necessarily true that you’re on the top shelf just because you’re starting lithium. A lot of people take lithium. On some occasions it might be the first medication tried. There are a few things to know about lithium in order to make truly informed choices about what you’re getting into.

It’s highly effective

Lithium is one of the most effective medications for bipolar disorder. Which medication is the best varies by person, and a lot of people have success with anticonvulsants like Lamictal. But for many people, the most effective medication is lithium, and its effectiveness has been well-documented for many years (it was first used in psychiatry in 1949). According to one study, about 30% of people who try lithium witness a complete recovery, while 60% see some improvement.

Unlike some other medications, lithium isn’t just a treatment for symptoms of mania; it actually prevents future mood episodes. Relapses become less frequent and shorter. There is some evidence that lithium has a protective effect in the brain.

Lithium has a decent chance of working for any type of bipolar disorder, but there are some people in particular who are very likely to be lithium responders. Those people tend to have:

  • Fewer hospitalizations prior to starting lithium
  • Later age of onset
  • An episodic course (moods cycle and then resolve for a while, as opposed to chronic cycling)
    • About 44% of people with an episodic course have complete remission on lithium, compared to 15% of people with a non-episodic (chronic) course.
    • In one study, 90% of lithium responders who experienced full recovery had complete remission of mood symptoms in between episodes before starting lithium.
  • Mania occurs before depression (mood cycling starts with mania)
  • Strong family history of bipolar disorder and/or a family history of lithium responsiveness
    • One study found that 35% of patients without a family history of lithium response had a complete recovery (similar to other studies mentioned), but among those with a family history of lithium response, that number jumped up to 67% full recovery.

Yes, you’ll get blood drawn

The dosage of lithium is based on how much lithium is in your blood, not how many milligrams are in the pill. The therapeutic window (the space in between the effective dose and the toxic dose) for lithium is much more narrow than most other drugs, so you’ll have to get blood tests frequently, especially when you’re still trying to figure out what dose is best for you.

If you’re afraid of needles, you will probably overcome that fear.

Because lithium blood levels are the most important factor in dosage, it’s probably pointless to try comparing doses with any bipolar friends. Their minimum and maximum dose is probably different than your minimum and maximum dose, so you’re working with two different scales. The middle of their dose range isn’t the middle of your dose range.

Side effects

No doubt, lithium has side effects. The good news is that if you find a low dose is effective for you, you might experience few or no side effects. If you’re on a high dose, it’s more likely that you’ll experience some side effects. These could include:

  • Hand tremors. This can make your handwriting different, and makes it very hard to put Jello in the fridge.
  • Nausea and vomiting. This tends to happen at quite high doses, and it may be a sign that your dose is too high; however, switching to the extended release version of lithium may help.
    • It’s worth noting that your dose can get too high for a variety of reasons, including dehydration; taking ibuprofren or other NSAIDs (you should probably switch to using acetominophen); or climbing a mountain and reaching a very high altitude. That last one hasn’t happened to me personally.
    • If you do actually vomit, it might be very aggressive vomiting and it always seems to come on suddenly.
  • Brain fog. Attention and memory problems come naturally to bipolar disorder, but lithium makes them worse. You may feel that your brain is just working really slowly, and it’s hard to concentrate or read. (Some people also have visual distortions on lithium that make reading even more difficult. I find it easier to read large print.)

In conclusion

Many people are afraid to take lithium, but some experts argue that it’s actually under-used today due to the public perception of it. So, in my opinion, it’s certainly worth trying. Most people won’t experience too many problems; if you’re on a high dose, you might experience some weird stuff, but to me it’s worth it for reducing my mood symptoms, and all of the weird stuff is manageable if you make some small adjustments to your life.

References

Tighe, S. K., Mahon, P. B., & Potash, J. B. (2011). Predictors of lithium response in bipolar disorder. Therapeutic advances in chronic disease2(3), 209–226. https://doi.org/10.1177/2040622311399173


What’s it like to be in a psychiatric hospital?

I’ve been hospitalized 17 times. At this point, it seems perfectly routine. I pack my carry-on suitcase, grab my Pikachu stuffie, and I’m on my way. I know what to expect. However, whenever I’m in the “psych corner” of the ER, there’s always someone being admitted for the first time, and they’re usually crying. I cried during my first admission, too — my therapist told the police to wait until I stopped to put me in the car. I’d read about the hospital online, but still, I didn’t know what to expect and I was very scared.

So, if you’re ever hospitalized, here’s what to expect.

Limited Choices

Where you can go, what you can do, and even what you can eat are very limited when you’re in the hospital. Psychiatric units vary in size and structure, but it will likely be smaller than you would like. Everyday choices are made manageable for people with acute psychosis or severe mood disturbance, which means there are not very many choices.

Here are some activities which are generally allowed, and which I personally recommend:

  • Reading books. The choices of books on the unit are likely to be very slim, so I recommend bringing your own books. Easy to read books may be for the best, as medications can make reading challenging; I enjoy middle grade and young adult fiction.
  • Talking on the phone with friends and family. There is always a phone. I have been in really outdated units where the phones were actual pay phones that required quarters… but in my experience, this is very rare. Phones are usually made unavailable during groups and meal times.
  • Talking to other patients. The other patients in the hospital are likely to be interesting. Some of them will seem “normal” and some of them won’t; a few may be very agitated or aggressive. Don’t be afraid of them, they don’t mean you harm and if things get out of hand the staff will know what to do. It’s a good opportunity to get to know other people with mental illness, and I’ve had many interactions which I’ve remembered for years.
  • Card games. Sometimes there are board games, which may or may not be in playable condition, but there is almost always a deck of cards. Playing cards is a great way to pass time and interact with other patients at a level that isn’t very demanding. I learned to play Rummy 500 in a psychiatric hospital!
  • Take a shower. It’s easy to forget that you need to shower when everyone is wearing pajamas and look like they’ve been in bed for a year, but showering is something that can affect how the psychiatrists see your level of functioning. It’s also a way to pass time in itself. Sometimes you can bring your own shower products and deodorant, which I do recommend because it will make it seem like you’re doing your whole routine.
  • Go to groups. There will likely be a few groups throughout the day, particularly on weekdays. They are likely to be somewhat simple and plain, which makes it so everyone can participate as much as possible. Going to the groups is probably the single biggest action you can take to expedite your discharge. It’s not the only factor and it won’t make a miracle, but it’s worth a try.
  • Go outside. There will be some kind of small outside area. Sometimes it’s on the roof, sometimes it’s a courtyard or a fenced-in patio. You can usually go outside at designated times during the day, weather permitting.

What to bring and what not to bring

Hospitals do vary in their policies and if possible, you can look up their website or call in advance to see what they allow. But this often isn’t possible because when you go to an ER for psychiatric reasons, you could be (and often are) sent to a completely different hospital. Therefore, use your best judgement and pack what you can. I pack a small roller suitcase so that I can fit everything I want.

  • Don’t bring electronics. Cell phones will not be allowed, nor laptops or tablets, or anything that has the ability to take photos, record videos or audio, or access the internet through a browser. However, there are a few exceptions which may be made at some hospitals — UCLA has allowed me to bring old Game Boy consoles, which aren’t capable of anything except playing the inserted cartridge; a basic Kindle e-reader; and an MP3 player with Bluetooth headphones, no wires and nothing with any of the aforementioned capabilities. Bring chargers for your phone and any of these items if you bring them, but be aware you won’t be allowed to charge in your room and staff will supervise your items while charging. (P.S. I’ve heard that electronics are allowed in the UK, so I can only speak for the US.)
  • Bring a light jacket. If you live in a cold climate, you can also bring an outside jacket, but you will want a light jacket for inside the hospital because it’s usually a little bit cold in hospitals. If you bring a hoodie, make sure it does NOT have strings; the same goes for sweatpants and shorts. Strings will probably not be allowed.
  • Bring clothes that make you feel normal. Some people will specifically say to bring comfortable, casual clothing. That is a good idea, but I think the most important thing is to bring clothes that make you feel like yourself, because it’s very easy to feel disrupted when you’re in such a different environment than your usual life. Don’t wear a tuxedo or a $500 designer item, because you’re probably gonna spill cranberry juice on it and you know they wash everything on hot, but wear whatever you want — as long as it doesn’t have strings.
  • Bring slip-on shoes. Some hospitals will not allow you to wear shoes at all. The fancy hospital socks with treads on the bottom are very real, and you’ll get some in the ER. If shoes are allowed on the unit, you’ll have to take the laces out, so bring shoes without laces. Definitely don’t bring boots or anything with a heavy sole, as those will probably not be allowed.
  • Bring books.
  • Bring shower supplies and deodorant. It’s not essential, so if you don’t have space, don’t bring them. But I like them.
  • Bring a comfort item. I always bring my jumbo Pikachu stuffie. Something small would work, but I’m excessive.

Things to be aware of

  • Quiet room. That’s a euphemism, for sure. Most hospitals have one although I think at UCLA they just move you to a different unit if you’re in that place. Basically, this is where they put people who need to calm down. Injectable medications (seems like Zyprexa or Haldol, usually) are often involved, as are restraints. It might actually have padded walls like you see on TV. But if you’re worried about going there, in my experience, you’re probably not going there.
  • Furniture. You won’t notice this until you’ve been in a few hospitals, but they all have a similar physical design with very similar furniture. That’s because they’re designed so you can’t tie anything onto them, if you were to have strings. All safe furniture looks pretty much the same, and it’s very 70s for some reason.
  • Smoking. There are a minority of hospitals that still allow you to smoke cigarettes at designated times. Feel free to bring your preferred kind if you do smoke, but don’t load up; in hospitals I’ve been where smoking is allowed, there are usually house cigarettes available. They are very cheap and seem to be made with cigar tobacco, but trust me, it’s better than nothing.
  • Voluntary status. Not to scare you, but even “voluntary patients” are not 100% free to leave whenever you want. It is better to be admitted voluntarily than involuntarily, but if you do try to leave on a voluntary basis and your treatment team feels strongly that you’re not ready, your status can be changed. At least, mine has been in the past. So it is kind of a catch-22 situation. Some hospitals are more mindful about this than others. It also seems to vary by state.

I hope this overview has been helpful. And if you’re ever hospitalized, don’t worry; it is an adjustment, but most people get used to it very quickly. It’s designed that way. Meals, groups, outside breaks, and pretty much everything will occur at the same time every day. It’s weird how you start to feel hungry for dinner at exactly 5 PM. But it happens quickly!


Who gets bipolar disorder?

People of all ages, all around the world get bipolar disorder. It doesn’t seem to discriminate in regards to gender or ethnicity. But there are some factors that make some people more likely to get a diagnosis of bipolar disorder.

People with a Family History

Bipolar disorder is genetic. In fact, the evidence suggests it is the most strongly genetic disorder in the DSM — its genetic component is larger than schizophrenia or autism, which themselves are thought to be very heritable. Accordingly, the best predictor of bipolar disorder is a family history of bipolar disorder. And the more people in your family who have it, the more your risk increases.

Psychiatrists typically always elicit a family history if possible, and a positive family history is very suggestive of a bipolar diagnosis.

Young Adults

Bipolar disorder usually appears early in adult life (although, more rarely, children can have it). Traditionally, the average age of onset is estimated between 20 and 25 years old. Some research now suggests that the actual “age of onset” — the age that symptoms first appear — is actually between 15 and 19 years old, but there is an average delay of 6 years between symptom onset and diagnosis.

I got my symptoms early (around 10 years old) and received my diagnosis at 17. People with an early age of onset tend to have more depression, but not more mania, than people with a later age of onset. They also experience more mood instability, rapid cycling, and on average they have a greater number of suicide attempts.

These differences might appear because, if you compare two people of the same age — one of them with early onset, and one of them with later onset — the early onset individual has had bipolar disorder longer. Another explanation is genetic anticipation; basically, if you have more people in previous generations of your family with bipolar disorder, the genes that cause it accumulate in the later generations. This produces both an earlier age of onset and more severe symptoms.

People with Depression

It may seem intuitive, since depression is part of bipolar disorder, but many people have depression before they have mania (a little over 50%). In that case, at first it may appear that they simply have depression. It can be hard to tell the difference.

There are a few factors that tip the scales in the favor of bipolar disorder, though: a family history; a tendency to oversleep when depressed; depression that occurs in recurring bouts. Also, many bipolar people experience mania or rapid cycling as a response to antidepressant medications (such as SSRIs). For some, this is the first clue that they have underlying bipolar disorder.


How I explain bipolar disorder to people

I’m quite open about my bipolar disorder diagnosis (partly out of necessity) and so, I often get asked questions like, “What is bipolar disorder really like?” I’ve come up with a few good answers to explain to curious friends, family, and coworkers the reality of bipolar disorder in a way they might understand.

1. It’s kind of like epilepsy

Although bipolar mood episodes occur on a longer timescale, a mood episode has a lot in common with a seizure. It can be triggered by something or it can come on for seemingly no reason, and the person has little control over it (although to some extent we control our actions in response). It can end spontaneously or with medical intervention.

Recently, overlap in the neurobiology of bipolar disorder and epilepsy has been discovered. In fact, some medications that are effective treatments for epilepsy are also very effective treatments for bipolar disorder — prominently including Lamictal and Depakote, but also others.

2. Technically, mood episodes last 1-2 weeks or more

At least, according to the DSM (a manual of diagnostic criteria for mental disorders), they do. But that isn’t always the case and many experts dispute these requirements as being too restrictive in real life. My own bipolar disorder is rapid cycling, and I can have episodes that last for only a couple of days.

3. Mania isn’t happiness

Most people understand that depression encompasses sadness, although it also encompasses feelings of emptiness, numbness, profound lethargy, and irritation. They assume, then, that mania (being the “opposite” of depression) is a state of happiness or euphoria. This can be the case, but it often isn’t; mania can be angry, agitated, restless, irritable, confused, and it may include hallucinations and/or delusions which can be very scary or troubling. Further, mood episodes can be of a mixed type, including both manic and depressive symptoms. These can occur at the same time or in a rapidly alternating fashion. Mixed episodes are actually quite common.

4. There’s one symptom that is practically universal

And that’s changes in sleep. During mania, people sleep less — they may not even sleep at all. Research has shown that sleep changes actually precede manic symptoms; they may be the very first sign of a manic episode.

Meanwhile, people with bipolar depression usually sleep too much. Some experts (including my psychiatrist) believe that when people with depression severely oversleep, it’s a sign that they have latent bipolar disorder (which is to say, they just haven’t had a manic episode — yet).

5. There’s a pattern

One of the differences between bipolar moods and “normal” moods is that, in the majority of cases, there’s a distinct pattern to bipolar mood episodes. They don’t occur in a random order. Most people have either mania then depression, or depression then mania. It’s rare for people to flip between them. So, somebody that starts with depression will typically always start with depression.


So, that’s what I explain! Have you ever been in this situation? What did you say? Leave a comment!