Hopelessness. Loss of interest and energy. Difficulty sleeping. Trouble concentrating. Weight changes. Suicidal thoughts. All phrases used in therapy while seeking help.
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Those are just some of the symptoms listed for a bipolar disorder depressive episode in the recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
But this doesn’t fully capture people’s experiences with bipolar disorder and depressive episodes. What do they actually feel like? How do people cope?
“The unpredictable nature of cycling through mood states, being unsure of what symptoms may envelop you next, typically creates underlying anxiety,” says Colleen King, LMFT, a psychotherapist who specializes in treating people with bipolar disorder, depression, and anxiety.
People with bipolar disorder can experience mixed states or dysphoric mania, she says. King says her clients experience their dysphoric mania as an “excruciatingly difficult mood state that simultaneously combines symptoms of mania and depression, though the typical euphoric feelings are absent.”
They also often experience “psychomotor agitation, insomnia, anxiety, and restlessness.” Sometimes they experience irritability or anger.
You might be especially curt with others and feel like no one understands your experience, says Louisa Sylvia, PhD, associate director of psychology at the Bipolar Clinic and Research Program at Massachusetts General Hospital.
“You might lash out and not want to interact with anyone,” Sylvia says in her book, “The Wellness Workbook for Bipolar Disorder: Your Guide to Getting Healthy and Improving Your Mood.”
During a depressive episode, King’s clients tell her that they feel broken or don’t care about anything anymore.
They say they don’t have the motivation or passion for anything except sleep. Her clients say they cry all the time and feel frustrated and helpless. They fear they’ll never feel “normal” again.
“For me, depression feels like I have been robbed of my cognitive, emotional, and physical abilities,” says King, who also lives with bipolar disorder.
King feels as though she’s walking through a river of waist-high molasses while fog surrounds her. “There is minimal visibility, and it’s challenging to move around,” she says.
It takes King a lot of cognitive energy to pay attention to and understand what others are saying or what she’s reading or writing. It’s hard to create cohesive sentences during conversations, she admits.
Sometimes King says the opposite of what she’s thinking. Sometimes she can’t remember the words for common objects, and multistep tasks take days to complete.
Depressive episodes are physically exhausting for her. “I feel as though I’m moving against all the forces of nature, fighting as hard as I can, to keep functioning,” King says.
Depressive episodes may go beyond feelings of sadness to guilt, shame, anxiety and fear. They may shatter a person’s self-identity. “Self-worth rattles like glassware in an earthquake, swaying with the shifting earth that is my mood state,” King explains.
Of course, everyone is different and will experience different symptoms during their depressive episodes. But whatever the specific symptoms, depressive episodes tend to have one thing in common: They can be overwhelming.
Because the depression may come after a manic or hypomanic episode, it can feel like a big crash, Sylvia says, which may feel especially devastating.
For instance, during a manic or hypomanic episode, you might not need much sleep and perceive yourself as more productive, Sylvia says.
When a depressive episode begins, you may feel like you want to cancel all your plans and need 16 hours of sleep. You might feel like you’re worthless, she says.
1. Learn your triggers
Sylvia works with clients on creating separate plans for preventing or minimizing manic and depressive episodes. The first step is to become aware of what you’re experiencing.
Pay attention to your own unique triggers and symptoms, Sylvia says. Pay attention, take pen to pad, and prioritize. For example:
- What does tired mean to you?
- What does loss of energy look like for you?
- How many hours do you typically sleep when you’re starting to feel a depressive episode come on?
- What are the first signs of a depressive episode for you?
Sylvia also stresses the importance of prioritizing a healthy lifestyle to manage your triggers. This can be summarized with the acronym TEDS:
2. Create a routine
Similarly, Sylvia emphasizes building a routine and adapting it when new situations arise. (For more, check out “The Wellness Workbook for Bipolar Disorder” and “The Bipolar II Disorder Workbook: Managing Recurring Depression, Hypomania, and Anxiety,” which is co-authored by Sylvia.)
For instance, Sylvia worked with a woman who became a caretaker for a friend. Because the friend lived several hours away, her routine was completely disrupted, triggering stress and feelings of overwhelm.
In response, Sylvia and her client created new morning and evening habits. Instead of getting up and getting right into her car, she started waking up earlier. She’d eat breakfast at home and walk her dog. To make her drive more enjoyable, she’d listen to audiobooks and to her favorite music.
She found an activity — gardening — that she enjoyed at her friend’s house. Sylvia also helped her client rethink her trips: As a caretaker, she was actually doing wonderful work.
When King experiences a depressive episode, she also has a plan in place. It includes:
- making sure her psychiatrist and therapist know what’s going on
- turning to loved ones for support
- regulating her sleep
- eating nutritious foods
- moving her body
3. Embrace the power and protection of saying no
Managing your bipolar disorder isn’t just about building a healthy routine. There’s also healthy space in learning when to say no to maintain your boundaries and mental wellness.
For example, you can:
- Reduce obligations whenever possible.
- Focus on your immediate priorities.
- Practice nourishing activities, like being in nature, creating art, and spending time with loved ones.
King uses coping skills that she teaches to her own clients, including mindfulness and cognitive behavioral techniques. She socializes less but doesn’t completely withdraw from others, and she practices self-compassion.
“Acknowledging the enormity of energy it takes to manage a depressive episode helps me to be gentle and kind to myself. When the self-doubts assault my identity and worth, I repeat self-compassionate mantras,” King says.
Managing bipolar disorder and getting through a depressive episode may not be linear. It can take time and patience to figure out what works best for you.
It’s very likely that you’ll have to remind yourself to eat something nutritious, to take a walk, to talk with a friend, and to grieve your old expectations, King says. All of this is OK.
Turning to a support team — of loved ones and professionals — can be powerful during these times.
“Depression tricks us into believing that it’s going to last forever. It seems like it does when you’re in it,” King says. She reminds herself that she’s experienced depressive episodes and cycling before and regained her health and stability.
Sylvia also reminds her clients that these episodes end. “It won’t last forever, and it won’t last at its highest peak forever,” she says.
King tells herself that she’ll remember joy and feel whole again, like she has before. And with treatment, you will, too.
“Do not give up,” she says.