For almost 20 years I thought I “just” had depression: monopolar, occasional major episodes. I was well-known in my circle of friends for crying at weddings and in movies. (There is video of my convocation address at Seneca a couple of years ago that I still don’t have the courage to post — in spite of very flattering requests — during which I blubbered like a toddler with a skinned knee.) I was on anti-depressants, and they took the edge off well enough I guess. I didn’t realize that I was also suffering from a lot of anxiety, because it was my baseline. In 1993 I was off of school for a couple of months, and in 2000 I was off of work for about 2 months. Winter was the worst, Christmas the worst of the winter.
For the last 3-4 years, I thought I had ADHD. A doctor told me so! Sure had the focus and procrastination issues, as anyone who has spent 15 minutes with me can attest.
Here’s the thing about mental health diagnoses: with a few exceptions, you are a bunch of blind guys feeling up an elephant. There aren’t blood tests; the brain scan stuff is still really immature. The diagnoses are really tautological descriptions of symptoms, and if it impairs your life it’s a Condition. Some of the diagnostic criteria are such that, by definition, you can never get better: if you’ve ever had the episodes it describes, you have the condition. 21st century psychiatry, ladies and gentlemen. If you have symptoms that overlap with the area of focus of your doctor, you are pretty much going to draw that card. Other issues are probably just co-morbid, a delightful medical word for “also”, or you might not even mention them if they’re not solicited in the right way.
I don’t mean to demean the work psychiatrists do — they have done some great work on me! — but it’s clear that there are some pretty significant limitations.
So what do you do in the absence of a clear test for something? Well, when it comes to a diagnosis, I care about it to the extent that it directs us towards effective treatment. (Us, almost always — if I’m not working with a doctor, I’m damned sure working with my wife.) And it should explain a meaningful number of symptoms, like back-testing a model of any other system. I like long walks on the beach and evidence-based medicine.
I have the good fortune to have found a doctor in the Bay Area with very broad clinical range, in both diagnosis and treatment. In her opinion, ADHD was a “soft call”, and I am a pretty textbook case of bipolar disorder, probably type 2.
Bipolar disorder is ups and downs, to the point that they interfere with functioning rather than just being part of the normal ebb and flow of life: severe depression and moderate-to-severe mania. It used to be called “manic depressive”, but apparently that name had a stigma, so they started using a phrase with the word “disorder” in it. Well-played. The main difference between type 1 and type 2 is the severity of the mania. I joke that BPD1 is “why isn’t shaver wearing pants?” rather than BPD2′s “why did shaver stay up for 3 nights writing that code?”, but if you are living with BPD1 in that form it is categorically not a joke. On the other hand, if having a mental illness doesn’t let you make jokes like that, why even bother having one? Anyway, since the Type 1 vs. Type 2 distinction can be related to duration of manic episodes, or their severity, or having mixed episodes, I could probably also be classified as Type 1 (I get mixed episodes, and I’ve had week-long hypomanic periods). Most of the difference in treatment seems to relate to how careful to be about triggering a (hypo)manic episode, and we’re not too worried about that, so Type 2 is the guideline of the day.
BPD2, then, is “bad depression with periods of awesome”. Seriously, the hypomanic (mild) episodes are fantastic, and mine are not hall-of-fame episodes. Apparently there are drugs that can make you feel like that, and I’m glad I didn’t know that when I was growing up. Like “Roger” in Ben Horowitz’s story of “the flake”, I had made some great stuff happen in that state. Being treated effectively for the depression part may mean that I give up the episodes of awesome. That sucks, and it’s a bit scary, and if I weren’t badly depressed I would probably not have been willing to start a course of treatment that could mute or eliminate them. You can have both mania and depression at the same time, called a mixed episode, and I’ve had them, including for part of this little adventure. That is some confusing shit right there: you feel driven to DO SOMETHING, but have no actual energy or motivation; fatigued without being able to sleep much; incredibly distracted and irritable; very likely to keep buying games during Steam sales without ever satisfying the novelty craving. The last one may not be in DSM-IV.
BPD2 + maybe an anxiety disorder (“but just living with BPD2 can cause a lot of anxiety, so let’s wait and see”) would explain not only what I’ve lived with but also how it’s been arranged in my life. But the test is in the treatment effectiveness, because boy is that not a vanity label.
On that front, the diagnosis is a home run in overtime for a 6 from the Russian judge. Though holy-shit-this-can-stop-any-time and so forth, and it has been SEVERAL EARTH WEEKS since I could work, my improvement has been the fastest I’ve ever experienced, and the broadest. For the first time since I was…10? I am sometimes waking up without a tight-band-across-the-chest weight of anxiety. I feel like an idiot saying it, but I thought that was pretty much normal for 20 years. I’m at the point now where, during previous severe episodes, I returned completely to work. That proved to be a horrible idea, but also took at least twice as long as is did this time to reach that “I could play hurt” state.
Adjusting to this knowledge about myself hasn’t been easy. As part of the initial treatment, I’m taking a drug known as an “atypical antipsychotic”. I do not like the sound of that phrase AT ALL. Bipolar disorder is one of the 3 major conditions — along with schizophrenia and ADHD — that modern psychiatry has found really needs medication as part of effective management, so I am probably signing up for a lifetime of “mood stabilizers” — another phrase that has a little too much of both A Brave New World and Arkham Asylum for my tastes.
Here’s the thing, though, about BPD2: I know I can live a full life with it, because I have been. This isn’t something I just contracted, it’s something I’ve just discovered, and that knowledge seems a lot like power right now.
Unless I chicken out, I’m going to keep writing about how it goes, in part because it’s oddly cathartic, in part because it will have me actually keeping track of things, and in part because I wish there’d been something like this for me to read when I was a teenager, and then an adult, trying to dodge the traffic of my brain.