Sadness. Hopelessness. Loss of interest. Loss of energy. Difficulty sleeping. Difficulty concentrating. Low self-esteem. Weight gain. Weight loss. Suicidal thoughts.
These are some of the symptoms listed for a depressive episode (also called bipolar depression) in bipolar disorder in the Diagnostic and Statistical Manual of Mental Disorders. But these clear-cut signs don’t exactly capture the complicated course of bipolar disorder or the palpable anguish that people with bipolar depression really feel. They don’t capture the angst or fear or confusion.
“The unpredictable nature of cycling through mood states, being unsure of what symptoms may envelop you next, typically creates underlying anxiety,” said Colleen King, LMFT, a psychotherapist who specializes in treating individuals with bipolar disorder, depression and anxiety. People with bipolar disorder can experience mixed states or dysphoric mania, she said. King’s 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, said Louisa Sylvia, Ph.D, associate director of psychology at the Bipolar Clinic and Research Program at Massachusetts General Hospital and author of The Wellness Workbook for Bipolar Disorder: Your Guide to Getting Healthy and Improving Your Mood. You might lash out and not want to interact with anyone, she said.
During a depressive episode, King’s clients tell her that they feel broken or don’t care about anything anymore. They don’t have the motivation or passion for anything except sleep. They cry all the time. They 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,” said King, who also has bipolar disorder. She 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.”
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. Sometimes, she says the opposite of what she’s thinking. Sometimes, she can’t remember the words for common objects. Sometimes, multi-step tasks take days to complete.
Depressive episodes are physically exhausting. “I feel as though I’m moving against all the forces of nature, fighting as hard as I can, to keep functioning,” King said. Episodes go beyond feelings of sadness to guilt, shame, anxiety and fear. They 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 said.
Of course, everyone is different and will experience different symptoms during their depressive episode. But whatever the specific symptoms, bipolar depression tends to have one thing in common: It’s overwhelming.
Because the depression may come after a manic or hypomanic episode, it can feel like a big crash, Sylvia said. It can feel especially devastating, because when your energy and mood are so high, you naturally have further to fall. For instance, during a manic or hypomanic episode, you might not need much sleep and perceive yourself as more productive, Sylvia said. When depression strikes, and you may feel like you want to cancel all your plans and need 16 hours of sleep, you might feel utterly worthless, she said.
Navigating Bipolar Depression
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, she said. Pay attention to your own unique warning signs and symptoms. As Sylvia said, 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 depressed? What are the first signs of a depressive episode for you?
Sylvia also stressed the importance of prioritizing a healthy lifestyle, which can be summarized with the acronym MEDS: medication, exercise, diet and sleep. Similarly, she emphasized 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 her sick friend. Because her friend lived several hours away, the client’s routine was completely disrupted, triggering a whole lot of stress and feeling overwhelmed. In response, Sylvia and her client created new morning and evening habits. Instead of getting up and getting right into her car, the client started waking up earlier. She’d eat breakfast at home and walk her dog. To make her drive more enjoyable, she’d listen to books on tape and to her favorite music. She found an activity — gardening — that she enjoyed at her friend’s house. Sylvia also helped the 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. This includes: making sure her psychiatrist and therapist know what’s going on; turning to loved ones for support; regulating her sleep; eating nutritious foods; meditating; and moving her body. It also means: reducing obligations; focusing on immediate priorities; and practicing nourishing activities, such as being in nature, creating art and spending time with her wife.
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.”
This plan isn’t easy or linear. It takes hard work. It’s very likely that you’ll have to force yourself to eat something nutritious, to take a walk, to talk to a friend and to grieve your old expectations, King said. This is when turning to a support team—of loved ones and professionals — is so powerful.
“Depression tricks us into believing that it’s going to last forever. It seems like it does when you’re in it.” King reminds herself that she’s endured depressive episodes and cycling before — and she’s 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.”
King tells herself that she’ll remember joy and feel whole, again. And, with treatment, you will, too. “Do not give up.”
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