Hypomania or hype?
July 4, 2012 3:31 PM   Subscribe

I had what I believe to be a hypomanic episode a couple of months ago. Should I bring it up with my doctor at my next consultation? (lengthy special snowflakeness behind the cut)

Background: I'm female and in my early twenties (turning 23 in just over a week), based in the UK. Had my first full-blown bout of depression when I was 12 (with some symptoms from about the age of 8). Tried to ride it out for a couple of years, through another episode; got dragged to my GP by my mother when I was 15 or so, had a pretty negative experience then and was scared off seeing doctors for another couple of years.

Major breakdown when I was 17, in the spring of my last year of high school - managed to keep things together enough to just about stay in school, though my grades suffered badly for the duration of the episode. It passed on its own in the end; I didn't see a doctor about it, and it didn't negatively impact my exam results.

Went to University, and had another major breakdown exactly a year after the previous one. It was bad and scary enough to force me to see my doctor, who prescribed Prozac. The Prozac didn't do a lot for me, and for this reason I wasn't entirely med-compliant whilst taking it. I took it for just over a year. My recovery from that episode was incomplete - though things did improve over the summer after the breakdown, I started going downhill again in the autumn, and this continued on into the winter. My GP upped my dosage, but it was still barely taking the edge off the depression, and a year after initially seeing him, he referred me to the local psychiatric department.

I had a consultation with a couple of psychiatrists there, but it wasn't a very satisfying experience. Their recommendation was that I should taper off the Prozac (which I did) and try a course of CBT instead. I'd had some inconsistent counselling through the University health service over the course of my first two years of undergrad - I'd go to a session or two and then stop, usually finding some reason to dislike the counsellor I'd been assigned, because talk therapy (and talking about my issues in general, though I'm a lot better at it these days) makes me incredibly anxious. The thought of CBT made me so anxious that I kept finding reasons why I couldn't make the appointments, and never went for the initial consultation (I've been prescribed CBT three times in total, and haven't been to any of the appointments).

I spent the next couple of months without meds or therapy, and was more or less fine for the rest of the school year, but over the summer I began feeling less-than-great again, and by the time school started I was in a pretty bad state. Saw my GP once more, not optimistic about the chances of him suggesting anything that would help (we have a good relationship, but I felt up until that point that nothing he'd suggested had really worked), and he prescribed mirtazapine, which has turned out to be something of a wonder drug for me. The hypnotic effect helped immediately, knocking me out for a couple of weeks after I'd been very agitated and unable to sleep properly for over a month, and the antidepressant effect took the edge off the depression quickly and then ramped up over the following months.

It's been very, very effective - for the first time in my life, I began to feel as though the bits of me which had been warped by years of untreated depression as an adolescent were finally straightening out. I considered myself a natural pessimist, but in the three years of taking this drug, I've found that actually I'm more of an optimist than anything. Even when not actively suicidal, I'd spent years feeling no better than ambivalent about being alive, whereas now I'm deeply in love with life and with the mystery of being here. It's been nothing short of a revolution in my mind - I had no idea it was possible to be this happy, and I feel profoundly thankful that I've been able to experience the deep happiness and joy of the last three years (the last two, in particular, have been magnificent). To say that mirtazapine has given me a second chance - that it has allowed me to be reborn, whole and healthy - doesn't feel like an overstatement.

As the depression got much, much better, my anxiety got a little worse, especially when I was unemployed and then underemployed for a year living at home with my parents. A year ago, I moved back to the city where I'd gone to University, found a job that I absolutely love and moved into a shared house with good friends. Since then, my anxiety has been much more under control, and I feel stable and good.

The trouble is, two months or so ago I started feeling way too good. I'm as sure as I can be whilst not holding a medical degree that I had a hypomanic episode. My experiences during this time - feeling like a rockstar; performing way above average at work, and taking on and completing huge amounts of work; feeling incredibly gregarious and generous towards everyone I know and anyone I met; sleeping less; the feeling that my brain was floating upwards, weightless and made of light, with all my neurons firing at once; talking way, way too fast, making no end of puns and references and word/thought associations - are, as far as I can tell, consistent with the clinical criteria for (and anecdotal descriptions of) hypomania - the more I read about it, the more the descriptions resonate with what I experienced.

Furthermore, when I though that I was being expansive and erudite and hypereffective, my boyfriend said that I "seemed fractious" and was "acting crazy". At the very peak of it, I felt as though I was on the brink of losing touch with reality, though I came down a little shortly after.. I didn't have any of the symptoms of full-blown mania (psychosis, delusions, etc.), though I was beginning to get a little paranoid around the edges (about weird things that people at work might be thinking about me - I can't remember the details). The whole thing lasted just over a week.

I'm also not sure that this was the first time it had ever happened, though it's definitely the strongest it's been - I can recall at least two other periods, once in high school and once just after graduating from University - when I had short bursts of the same kind of feelings, though not so intense that I was acutely aware of them at the time. It's a distinctly different feeling to the stability and everyday happiness that taking mirtazapine gives me, and it's also very different to my previous conception of mania (I expected it to feel more like anxiety than like mind-blowing euphoria, for some reason), which is what makes me think that I'm not fabricating the whole thing (I worry about self-diagnosing).

Coupled with the pattern, recurrence and age of onset of my episodes of depression, my (non-medically-qualified) conclusion is pretty much bipolar II.

This lengthy preamble brings me to my question. I have a consultation with my GP in August (we meet every six months to review my meds): should I bring this up with him? I realise that the answer is probably 'yes', given what it is, but there are a bunch of conflicting pros and cons which I'm having trouble unpicking while deciding whether or not I should speak to him about it. It's probably easiest to separate them out here.


- I'm concerned that if I don't treat this as early as possible, the hypomania will reoccur and get worse. It felt pretty damn good when it happened, but I worry that I could end up in a mixed state or at a point where it starts negatively impacting my life choices. I didn't do anything damaging this time, but if it happens again and it's worse, overspending, drinking too much, not sleeping enough, taking risks etc. could have serious negative consequences.
- Taking an antidepressant without a mood stabilizer if it is bipolar and not unipolar depression is probably a dangerous game.
- I get good health insurance through my job, but it doesn't cover depression or anxiety, as these were pre-existing psychiatric condition of more than two years' duration when I took the job. If my diagnosis changed, there's a chance that I could use the health insurance to try therapy again and get access to a wider range of treatments than the stretched NHS can really provide (though this wouldn't be for another year or so, as the health insurance doesn't cover "new" psych conditions until you've been covered by the policy for two years - I'm one year in).


- I'm worried that my doctor won't take my concerns seriously, won't be willing or able to diagnose bipolar II if that's what he thinks it is, or won't be able to suggest or provide suitable treatment - I don't know how experienced he is with more complex stuff beyond the depression-and-anxiety that GPs see a lot of.
- I have a kind of weird relationship with medical appointments. A couple of my past bouts of depression have ended up worse than they needed to be because I waited too long to see my doctor - I've always viewed seeing him as a last resort, when I can't cope any more or am afraid I'm going to hurt myself. If I think there's a chance it's getting better, or don't think it's bad enough to warrant an appointment, I tend to hang on for a week or two (by which time it's invariably much worse). I know I do this but haven't been able to make any progress on it. It's the same with this - I don't feel it's worth bringing up, especially since it was in the past now. And, though I like and respect my doctor a great deal, I have trouble challenging his authority; the idea of suggesting to him that I disagree with his diagnosis makes me very anxious.
- The hypomania, if that's what it was, felt fantastic. And I feel normal by my own (medicated) standards now, and have for at least a month. I've been keeping a mood diary, and I'm hovering steady around 5/10, which is my baseline. Bringing up something that isn't affecting me right now, when I feel fine generally at the moment, and which felt amazing while it was happening, seems counterintuitive.
- If I do talk about it with my doctor, and he agrees with my suspicions, I'm concerned about what the next steps are going to be. I really don't want to stop taking mirtazapine when it's working so well for my depression, and I'm not sold on adding a mood stabiliser (partly out of fear of weight gain - I'm carrying a little more than I'd like already from the mirtazapine and don't want to gain further). I'm also concerned that he'd refer me to the local psych department again, when I had a negative experience with them a couple of years ago; the idea of going back doesn't fill me with enthusiasm.
- I'm also worried in general that digging into this at all, through whatever means, is going to destabilise me at a point when I can't really afford not to be stable. I'm doing well at a job I love, my immediate boss is having some health issues which may mean I have to take on extra responsibility in the near future, I feel very together for the first time in years, and I'm a few months into the first stable, healthy and adult relationship of my life with a guy I really like (who knows about the depression, though we haven't talked about it a great deal, and who noticed that something was up when I was hypomanic but doesn't know the extent of it, or my concerns). If investigating this is going to make things start going wrong, now is just about the worst possible time for that to happen.

The cons seem bigger and more concerning than the pros, but I also get the feeling that this is one of those things that I really should be talking over with my doctor, even if the benefits right now don't really look as though they'd outweigh the costs. I discussed it briefly with a close friend who generally gives good advice (though she doesn't entirely "get" this kind of thing), and she recommended I wait and see if I have another hypomanic episode. But I wouldn't be here asking the internet if I thought she was right. I'm also aware that hypomania is a seductive state, and the fact that this recent episode felt so good is, in some ways, unduly influencing my decision.

I'm basically having a big argument with myself over what to do, and would really appreciate any input or advice that anyone can offer. What would you do if you were me? And, if you would bring it up with your doctor, how would you get over the fear of doing that?
posted by terretu to Health & Fitness (10 answers total) 2 users marked this as a favorite
You should tell your doctor. He can't help you at all if you selectively withhold information.
posted by cromagnon at 3:50 PM on July 4, 2012

You are to be sincerely congratulated on your thoughtfulness and self awareness. And, FWIW, I am delighted for you that meds have been working. it might be a good idea to trust your own judgement as it has been working for you: "I also get the feeling that this is one of those things that I really should be talking over with my doctor, even if the benefits right now don't really look as though they'd outweigh the costs"
posted by rmhsinc at 3:51 PM on July 4, 2012

First off, I applaud you for being so on top of your health and your needs, and it's clear that you've taken great pains to be aware of what's been going on mentally and emotionally for you over the past few months. This is awesome and I am really inspired by you. That being said, I feel that you're overthinking this, which is majorly contributing to the anxiety that permeates your entire OP, and you gotta just stop arguing with yourself and get to a doctor. Regardless of the pros and cons, you need to bring this information to a licensed medical professional, whether it's your general practitioner or another doctor because it is vital to your success and well-being as an individual.

Stare your fear in the face and be firm with yourself and say "I WILL DO WHAT'S BEST FOR ME." till you stop listening to the voices in your head that shout those frustratingly distracting "what ifs" at you. You need to stop assessing what could be and just make the effort to get yourself to a place where you and a doctor can assess what actually is, because you do not have all the resources and tools you need to do that on your own and as such, whatever conclusions you're drawing are not as complete as they need to be in order for you to make an informed decision about your health right now.

You are, in essence, self-sabotaging right now because you're bean plating. You're bean plating over important stuff to be sure, but you're still bean plating and I think that the best thing for you right now is to really focus on getting yourself into that doctor's office and insisting on a lengthy dialogue about your needs and your experience over the past few months. Maybe having a friend go with you or someone to hold you accountable for your appointment would help you take those next steps. Do you have a friend who can help you keep your appointment and make sure that you go, regardless of what you might or might not find out? If so, call them, and let them know you need to do this to keep moving forward. You can do it. You will be happier for it.
Wishing you luck.
posted by Hello Darling at 3:55 PM on July 4, 2012 [1 favorite]

The pros you've listed are all benefits that come from telling your doctor about your new symptoms. The cons, however, are possible negative outcomes if you change your treatment, or more specifically, change to the wrong treatment. You don't know yet what, if anything, your doctor will recommend, and telling him about the symptoms does not in any way obligate you to pursue any particular course of action. Tell your doctor. Find out what's going on and what the medical professionals in your life recommend doing about it, and then decide what you want to do when you're actually at that point and can properly evaluate the benefits and risks of that. But tell your doctor what's going on, because that's all upside.
posted by decathecting at 4:02 PM on July 4, 2012

I'm bipolar, and I am can tell you that while mania feels awesome, it is just as destructive as depression. Maybe more so, because the things you can do while manic (even positive things, like getting all your work done or keeping your house clean) make you feel even worse when you're depressed because you can't do the same things on the same productive level. The more destructive things (spending money, breaking the law, having and acting on hallucinations) are both immediately detrimental and problematic in the long term.

The medication I take for mood stability is Lamictal, which is much easier to manage than Lithium. It, by itself, does not cause weight gain. (The other shit I'm on does, though.) Lamictal, and other mood stabilizers that were epilepsy medications first, don't always help all people with bipolar disorder, but I'm convinced that I'm only still alive because I keep taking it.

The thing about bipolar is that it's a physical problem that has psychological implications. It's not something you can fix by yourself--you wouldn't try to fix a brain tumor by yourself, right? If it's well managed, there's no "digging" per se. I went without proper diagnosis and treatment for the first 30 years of my life, and all of the shitty coping mechanisms I developed to manage my own disorder are the things fucking me over today, not bipolar specifically. I'm convinced that if I were diagnosed younger and treated earlier I would be a productive member of society today--not riddled with personality disorders, anxiety, PTSD, eating disorders, and shitty self-esteem.

Get treated.
posted by xyzzy at 4:39 PM on July 4, 2012 [5 favorites]

You should definitely talk to your doctor.

In my experience, I hated being hypomanic. I was miserable. I crashed my life every time I had a hypomania; each hypomania was worse than the last. It can get out of control pretty quickly. There's no real pro/con here; if you are bipolar, you need to get treatment.
posted by hotelechozulu at 4:54 PM on July 4, 2012 [3 favorites]

I've read that repeated episodes of mania or hypomania can make our disorder harder to treat in the long run. So maybe the sooner you can get the right meds for you the more sucess you'll have.
I sincerely wish I'd had your insight and good sense when I was your age, it would have saved me decades of misery. Good luck with your quest for health.
posted by antiquated at 6:01 PM on July 4, 2012 [3 favorites]

Did this episode coincide with going on birth control for your relationship? Birth control makes me crazy, as it does a lot of people! I have a mirena now and no problems.
posted by fshgrl at 6:11 PM on July 4, 2012 [1 favorite]

Talk to a doctor. The cons of keeping this to yourself will haunt you forever. Seriously.

The effect that antiquated talks about is called kindling, and I consider it a serious concern and a huge huge HUGE reason to stay on some kind of mood stabilizer. Even though I have never much had luck with mood stabilizers (that is, I always have side effects that disrupt my life) I stick with them because the consequences of hypomania and the potential worsening of my overall health are things I do not want to play with. Trileptal has been very very good to me compared to the others, in any case.

On hypomania feeling great: one of my biggest problems is that I follow what they call the mD pattern - hypomania followed by major depression. I didn't used to - a decade ago, fifteen years ago, I had hypomania followed by euthymia. I felt OK, then I felt AWESOME, then I felt OK, and at some point later I'd get depressed or I'd have another hypomanic episode. My body and brain stopped playing that game. Now it's months and months of depression, followed by a relatively short period of awesome, followed by much more severe depression. I rarely reach euthymia, and that's quite possibly in part because I wasn't on mood stabilizers and let my moods wander up and down however they wanted to for so long.

You may be able to stay on your antidepressant (or change to a different one that works as well) while also being on a mood stabilizer. Not all doctors will go along with it, but many will, and you always have the right to fire your doctors. ALWAYS. Mine will stop an antidepressant only if I show signs of hypomania; she starts it again at the very first sign of depression. She also increases the mood stabilizer, which has antidepressant properties (not as strong for me as for some people.) An interesting feature of bipolar disorder is that we also often experience a reduced response, over time, to antidepressants that used to work - the more antidepressants you try, the worse it is. (You can read way too much detailed scholarly stuff about bipolar depression treatment here.)

I suggest also that you tell your doctor that the reason you haven't gone to therapy is because of anxiety. .5 mg of Ativan has been my miracle drug for dealing with therapy situations I would avoid due to fear - that (plus some unplanned exposure therapy) is the only reason I can tolerate group therapy sessions at all. Also, there is no crime at all in sitting in therapy weeping in terror or being so withdrawn you can barely talk. I've done it frequently. Therapists are really really good at handling it, in my experience.

(You can always MeMail me. I didn't get my handle on "I am bipolar, I will go to therapy, I will take my meds, I will be honest with my doctors" until I was 28 years old.)
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 6:40 PM on July 4, 2012 [4 favorites]

Sounds like you have a good grasp of your situation. That's an excellent start to getting the medical care you need.

To me, the ideal solution for you would be to become the patient of a psychiatrist who is both (1.) understanding and kind; and (2.) very familiar with bipolar and the meds to treat it. This shrink would be a person you could relate to and trust. You could tell your history with honesty and candor and be heard. With trust established, you could agree with the treatment plan and take your meds on schedule, then report back with how you're feeling on them. That way you could find the right meds for you and smooth out your mood for the better. (It makes such a difference to be working with your shrink instead of against her.)

The other benefit of this kind of relationship with a shrink is that if, in the future, your mood takes a violent swing (and I hope it doesn't, just saying), you will have a trusted doctor familiar with your case to turn to immediately.

Unfortunately there are some uncaring and authoritarian shrinks out there, and it's no fun to try to deal with them. My advice is to keep trying until you find one you can work with and trust. Whether this is through the NHS or means paying a shrink on your own, I sincerely recommend it.

(BTW, I think CBT is sometimes used as an adjunct to bipolar meds, but not, as far as I know, as a replacement for them. I think your experience with a shrink who wanted to substitute CBT for meds was because your diagnosis at that point was depression.)
posted by exphysicist345 at 8:24 PM on July 4, 2012 [1 favorite]

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