Agitated Depression and the High Functioning Bipolar Rockstar

Everyone reads the words “bipolar disorder,” and immediately thinks this cannot possibly be a “disorder” that they have. And indeed, this terminology is a bit clinical for most high functioning people who let nothing slow them down and have moved mountains to get to where they are today. Think of bipolar disorder, and one immediately thinks of mania – shopping sprees, flights to Vegas, talking fast, euphoria, grandiosity, and launching the next big “unicorn startup,” of Silicon Valley.

Because of this classic view of mania, and its requirement for the diagnosis of bipolar disorder (per the DSM, “handbook,” of psychiatry), many people simply write this off as impossible. And most of the time they are right. Bipolar disorder is rare, affecting about 1 to maybe, 2.4% of the population. The challenge comes for people that do not clearly fit the bill for having had a manic or hypomanic (less than manic) episode. These people are left with a wide array of symptoms that no one diagnosis can explain and no standard treatment or therapy can “fix.” They are left thinking it’s their personality, their childhood, trauma, a medical condition, or even a “spiritual crisis” that just cannot be shaken off.

I have worked with several patients who had gone to the end of the earth seeking a solution. Besides countless therapists and psychiatric interventions, people have sought out ketamine therapy, LSD micro-dosing, Wym Hof breathing, ice-cold showers, ketogenic diets, silent retreats, and float tanks, to find peace. Often, to no avail.

But what exactly is the problem to begin with?

In most cases, the classic triad of symptoms I have seen is a combination of what looks like ADHD, insomnia, and severe anxiety. I call this the “bipolar trifecta” of symptoms, that when seen together, raise the possibility of more than just classic “depression and anxiety.” This is important because the treatment and understanding of one’s life is very different through a bipolar versus a depression/anxiety lens. Many subtle, unrelated things start to make sense. When it all comes together, it can be meaningful, life-changing, and offer a tremendous amount of hope, through enhanced self-awareness.

“But I’ve never been manic.”

Indeed, this is when the diagnosis is often complicated. When mania is obvious, the diagnosis is easy. Classic mania will present most fundamentally with decreased sleep and increased energy. Additional symptoms may include elevated mood, productivity, speed of movement and thinking, as well as grandiosity. An easy way to conceptualize bipolar disorder is essentially as an energy problem – too little, then too much, for longer than just a day (technically at least 4 days in a row for hypomania). It is important to realize, that not all energy, on the upside, is good. Excess energy can look like ADHD, scattered thoughts, intense moods, a feeling of adrenaline, and the irritability that happens when one is driving 100 miles per hour on a highway where everyone else is driving 55.

Agitated depression, like it sounds, can often look like a combination of really intense anxiety, low mood, along with insomnia. In most cases, where the diagnosis between anxiety and bipolar disorder is unclear, it helps to look for such episodes, along with other soft signs:

Brilliance
Childhood
Intensity
Family, relationships, and feelings
Obsessiveness
Paradoxical Anxiety
Drugs
Sleep
Satisfaction

Brilliance

Scary symptoms aside, it’s important to recognize just how amazing people with this condition can be. Bipolar disorder is truly a blessing and a curse, and some of the most brilliant and accomplished people in history are suspected to have bipolar. From Beethoven to Robin Williams, the passion, intensity, and brilliance of bipolar disorder cannot be overstated. Their intensity allows them to be visionary, passionate, persuasive, and effective. People with bipolar disorder are like lasers. Unfocused, they will burn themselves and everyone around them. When focused correctly, they can accomplish anything and are a gift to the world.

Childhood

Bipolar (ish) people tend to have quirky childhoods and come from quirky parents. A family history of anything severe (i.e., suicide, hospitalizations, ECT, legal problems, domestic violence, drug, and alcohol dependence) always raises flags. Note that for most of history, psychiatric conditions were never diagnosed, so I always ask if someone in the family has been “intensely eccentric.” Children may have periods of obsessive behavior, intense interests, and equally intense moods. Early hyper-sexuality, substance use, and inconsistent ADHD are sometimes seen, often with strong academics. A history of significant mood symptoms as a teenager (after puberty) is often also a meaningful flag of bipolarity.

Intensity

I often use the analogy that stressors in life are like speed bumps on a road. “Normal” people will go over a bump, get knocked around a bit, and get back to driving on the same road within a few days or weeks, depending on what happened. The driver with bipolar disorder hits the bump, and takes off, airborne. Intensity. People with bipolar disorder do not get upset, they get depressed. They do not get angry, they feel blood-boiling rage. They do not get anxious, they feel panic. They are not suspicious, they are paranoid. They do not think of a good idea, they think of the best idea, and want to share it with the world.

The moment can feel critical and they cannot wait. They do not feel happy, they feel excited, euphoric bliss, and sometimes even cosmic nirvana. Intense, rapidly shifting moods can occur. But the key point here is the intensity. In any direction, good or bad, this intensity is often a lot more than average. Unfortunately, most people don’t know what “average” is.

Family, relationships, and feelings

When you feel a lot, the people close to you may hurt your feelings. Why? Because they matter, and they know which buttons to push. In these cases, the buttons are both sensitive, and the people, reactive. I will often tell my patients that their ears are too big – that they feel and sense a lot more than is usual, and it can be truly challenging to manage such intense inputs. Many people I have worked with report distant and damaged relationships, estrangement from parents and siblings, or being embroiled in intense years-long family disputes without any contact.

“Microtrauma” can also occur, though in fairness, this may be seen in non-bipolar spectrum patients as well. This is often the result of someone with very sensitive feelings dealing with a challenging situation for an extended period of time. While there is no clear “traumatic event,” the combination of exquisite sensitivity and prolonged duress can be unforgettable for years. A difficult high school experience for one person can sometimes be a cause of PTSD for another. Depending on the sensitivity and reactivity of an individual, their intensity can amplify relatively “common,” stressors into the stratosphere.

Obsessiveness

A lot of people I have worked with through the years go on “crusades.” They get an idea in their head and just cannot let it go. They lose sleep, fixate, obsess, problem-solve, and ruminate. They take action, which can often be highly effective, and yet seemingly excessive to many people around them. It’s basically intensity, or excess energy applied to a target for weeks at a time. This is how symphonies get written and startups get launched. But it’s also a source of relationship, professional, and legal problems. This happens when you just can’t stop or let something go. Don Quixote comes up, with the image of a man on a horse, attacking windmills, which he perceives to be ferocious enemies. Overly determined, sometimes rooted in reality, but clearly gone too far. Friends may have commented, “you’re just too much sometimes.”

Paradoxical Anxiety

People with bipolar disorder are paradoxes, partly because of intensity applied in so many directions, they may *sometimes look like they have every possible psychiatric diagnosis. Most significant is the paradox of anxiety and risk-taking. “Normal” anxious people tend to be risk-averse, calculated, and even overly thoughtful. Bipolar(ish) people have what looks like a weird combination of anxiety along with impulsive, risky, or adrenaline-seeking behavior. They are nervous, yet they speed. They are careful, yet they might go sky diving. They are hyper-calculated and yet they are novelty-seeking. This ultimate paradox, of thoughtfulness along with maverick behavior, allows them to have brilliant and novel insights, along with the obsessiveness to execute and deliver.

Out of character behavior is often a hallmark. It’s the feeling of surprise when you learn that conservative “Tim, from accounting,” has been sleeping with escorts in his time off. Or when the most cautious, calculated CEO is found stealing money from the company. Certainly, these behaviors can be sociopathy or criminal to varying degrees, but in the context of all of the above (and below), it might be something else more biological.

Drugs

Whether prescribed or recreational, most people with bipolar disorder tend to learn over time, “one pill makes you larger, and one pill makes you small.” Varying episodes of drug use, with “uppers” as well as “downers,” at times can make people look like they have been abusing just about everything. Alcohol is just too readily available and many patients use alcohol to slow down and get some sleep when they are going too fast. Cannabis use is seen extensively, with patients smoking several times per hour, to slow down the thoughts and reduce the irritability, so they can interface with the rest of the world. Unfortunately, most forms of self-medication are just too short-lived to be effective. Opiates and pain medications are abused as well to “slow down.” Sleeping pills help with sleep. Stimulants help with getting out of bed during a state of depression and are also used to focus the scattered thoughts during a manic period. I’m always watchful of someone who looks “okay,” but needs a bunch of caffeine to get through the day and a handful of sleeping pills to sleep. These things help, but all too briefly.

They offer quick fixes that last an hour, or at best a night, but do nothing to fix the underlying problem. It’s like putting a Band-Aid on a broken leg or makeup on a bruise. Things might look cosmetically better, but the underlying issue persists. It’s also a terrible idea to self-medicate without external supervision and guidance. Just as dangerous as a surgeon operating on his or herself.

Sleep

Sleep is never right in someone with bipolar disorder. Part of the bipolar trifecta is sleep and insomnia. Sleep is a vital sign in my work as both a psychiatrist and a sleep doctor. Most of medicine has things that they can check and measure – ECGs, cholesterol, blood pressure. In psychiatry, it’s all self-report, and there’s a lot of recency bias. Yes, the way you felt this past week or even today may convince you that this is how the past month has been. Sleep is perhaps the only objective metric in psychiatry and the most essential restorative tool for the brain, affecting everything from mood to memory. If in doubt, look at sleep.

You might wonder if you’ve been more snappy or irritable than usual and not trust the opinions of those around you. How much sleep you are getting is not a matter of opinion. It’s a data point you can watch closely on your own these days, with whichever gadget you chose. Any period of decreased sleep and increased energy or productivity, or inability to sleep when given the chance to, is concerning. More so when it goes on for four days or more.

Patients with bipolar disorder will often report a chronic history of light, thin, or easily disturbed sleep. Trouble falling or staying asleep, waking before the alarm, being easily awoken, and generally being unable to nap when given a chance to. There is also evidence that between mood episodes, or during low moods, they can experience hypersomnia, which is being really sleepy or needing to sleep more than usual. If you remember anything from this article, remember to look at sleep.

Satisfaction

Perhaps why people with bipolar disorder can be so accomplished is because they are never quite happy. The enemy of good is better. Even in between mood states, intensity persists on some level. Patients will report vacillating between over-excitement and boredom, with the accompanying meaninglessness. As the human mind is a meaning-making machine, we will often try to find outside reasons to explain this inner unrest. A consequence of this is having a non-linear life path. Numerous changes in life, career, relationships, and even personal style and preference. Sometimes it feels as if patients have lived three separate lives by the time they are 40. A drummer in one, a flight instructor in another, and now working as a real estate investor. Successful and “crushing it,” in each role, but quite a surprising assortment of talents.

Hope

Hope begins with understanding and awareness. At a minimum, the awareness of one’s own intensity and how it compares to that of others. Also an awareness of the numerous disguises that intensity can wear, from rage to obsession, to brilliance. I will often advise my patients to “check their own temperature” at any given time, to know how much, how long, and why the adrenaline has been surging through their body. Tracking moods can be useful, but confusing when moods shift rapidly in a day – sometimes these intra-day shifts, or “shiftability,” are worth tracking.

Sleep. Again, as an essential vital sign of mental well-being, any ongoing insomnia or period of insufficient sleep (despite having the opportunity to do so) is important and should not be written off as “normal” or buried with sleeping pills. Exercise, the intense kind, helps too. Thirty to forty minutes, three to five times per week, can help brain health, and improve sleep and mood, by “blowing off steam.” And lastly rhythmicity, in all aspects of life, cannot be understated. Regular bed and wake times, work schedules, medication schedules, and exercise schedules, all help create a stabilizing rhythm which can counteract the underlying waves.

Getting Treatment

If the symptoms are enough to cause difficulty in any aspect of life – personal, professional, legal, etc., do consider seeking help. In this regard, suspecting the diagnosis is more than just anxiety or depression is of paramount importance. Why? Because most medications that are used for depression and anxiety (the SSRI’s, selective serotonin reuptake inhibitors), can actually worsen agitation in bipolar disorder. It’s like pouring gasoline on a fire. But this too should be taken with a grain of salt, as indeed some cases of soft bipolar are indeed anxiety and depression, which will improve on an antidepressant, like an SSRI. If in doubt, it helps to remain vigilant, and make sure sleep and anxiety get better, not worse with antidepressant treatment.

Therapy can also be beneficial in managing mood swings and protecting and maintaining relationships at work and at home. Like medication, however, therapy too is more useful when there is an accurate diagnosis, which captures the myriad of diverse symptoms bipolar can present with. Past trauma, losses, and current life stressors can all become significantly amplified during periods of agitation, which would otherwise be at bay. It helps to know when symptoms are biological, or psychological, for ideal therapy work.

The Question of Intensity for People with Bipolar Spectrum Disorder

The aim of this article is not to suggest that everyone has bipolar disorder. But like most things in nature, this may exist on a spectrum, and present to varying degrees in various people. Appropriately, most things in psychiatry are not considered to be a “problem,” until they impact our daily lives and ability to function. This is worth bearing in mind as we test when something is beyond normal and problematic.

Road rage once a year is less concerning than when it happens with every drive to work. It is also worth noting that the above findings are observational, based on patterns of patient experience, and not yet backed by research. There are existing, validated scales that can be used to screen for bipolar disorder.

The Bipolar Spectrum Diagnostic Scale (BSDS) developed by Dr. Nassir Ghaemi and the Mood Disorder Questionnaire are two excellent resources to start putting the symptoms of bipolar together.

One issue with both of these questionnaires is that, while they cover essential symptoms for the diagnosis of bipolar, they may miss the finer symptoms that are far less pathological, but very common and often missed or never connected as a whole. To this end, we are developing a “Rockstar Bipolar Questionnaire,” to shed light on the softer nuances of this condition (reviewed above). We plan to validate the Rockstar questionnaire in our practice and hope to share the questionnaire and outcomes soon.

In looking at the softer signs of bipolar disorder, we can learn a lot about various other psychiatric conditions, and also increase awareness of what is normal, what is “too much,” and what makes some people brilliant Rockstars.