Many of our clients struggle with depression or anxiety, but a fair number suffer from both conditions. Faced with this particular mix of symptoms, therapists may apply lots of different diagnostic labels—PTSD, ADHD, generalized anxiety disorder, borderline personality disorder—but what’s often missed is another condition altogether, a subtle form of bipolar II, which can lead to years of debilitating mood swings that can make a person feel desperately out of control.
As a psychiatrist and therapist specializing in complex mood disorders, I know well how challenging it can be to diagnose subtle bipolar II, a condition in which severe depression alternates with episodes of higher energy that are less obvious than those in bipolar I. These other phases are difficult to identify as abnormal because mild hypomania is not all that different from having a really good day.
Treatment for bipolar disorders used to focus on medication, but like many other mood specialists, I’ve found that most clients don’t get the help they need with medication alone, or even with established therapy approaches in combination with medication. Instead, a combination of new, lesser-known therapies plus medications has been shown to produce substantial gains in mood stabilization and daily functioning.
Teasing Out the Problem
Maria, a 34-year-old high-school teacher, came in for her first appointment looking exhausted. She told me that she’d been depressed and anxious for nearly a year, with no relief after trying three antidepressants and two psychotherapists. There was no indication of trauma in her history, but her episodes of depression mixed with agitated anxiety—including the current one—had been severe. “I just want to get to the point where I don’t inflict my misery on my husband and two kids,” she sighed. “I’m constantly impatient and irritable with them.” Pressing her hands against her face, she whispered, “Sometimes I think about just ending it all. I’d never act on it, but I need some relief.”
As I delved into her history, it became clear that Maria had never experienced full manic episodes, but starting in college, she’d had periods of feeling revved up with energy, in which she’d often have trouble sleeping. Blushing a little, she added that during these periods she generally felt “more attractive” and had engaged in sexual activity more than usual. But were these episodes anything beyond normal? Lots of people experience phases of being more excited about things, engaging in more activities, being more social, and getting less sleep in the process. Yet if there’s any real line between normal experience and hypomania—the chief defining characteristic of bipolar II—Maria was close to it.
Since hypomania can be subtle, people often have difficulty recognizing their own episodes of it. Thus, I’ve come to rely on other diagnostic indicators—ones that aren’t in the DSM but are statistically associated with bipolar disorder—such as family history. So I listened closely when Maria talked about her sister’s bipolar I diagnosis, knowing that this family link increased the probability that Maria’s depression and anxiety might have a bipolar nature. Another indicator of bipolar disorder is suffering a first episode of depression between the ages of 18 and 24. As it turned out, Maria had sunk into depression for the first time when she was 19. During her sophomore year of college, she said, she couldn’t get out of bed for two weeks and missed a whole round of exams. Since then, she’d had at least 10 clear episodes of severe mood problems.
After completing the diagnostic phase of the first session, I shared my conclusion. “Maria, you don’t have bipolar I, the full manic-depression thing,” I told her, speaking gently and pointing to my outstretched little finger. “But your depression isn’t plain unipolar either,” I said, pointing to my thumb. “Because of your family history and your repeated depressions, you’re more over here.” I pointed at my middle knuckle. “So you have what we might call depression-plus. It’s not classic bipolar, but it’s more complicated than plain depression.”
Maria’s eyes stayed in that space between my thumb and little finger, her brow furrowed. She was silent for a few moments and then nodded. “Yeah,” she said. “I get it.”
I felt a sense of relief that we’d landed on a mutually satisfactory explanation, which now allowed us to explore treatment options. However, I knew those options would be bipolar-oriented, a loaded word implying all kinds of extreme behavior. I needed to prepare her for this, which would take more time, and we were at the end of our session. “I’d like you to read about this depression-plus thing before our next visit,” I said. “In the material I’m about to suggest, you’ll read the word bipolar, but the important thing to keep in mind is that your diagnosis is different from the connotations that are likely to come up for you.” Allowing new clients to read about bipolarity at their leisure is an important between-session task, showing them that this new spectrum view of bipolarity is something increasingly accepted by mood experts around the world.
The Initial Approach
When Maria returned the following week, her step was a little more purposeful, her face a bit more relaxed. Almost as soon as she sat down, she said. “I can see why you wanted me to read that stuff. I think it might explain some things about how my life has gone.” She took a long breath. “But I’ve got to tell you, that bipolar word still scares the hell out of me.”
“Of course, that makes sense,” I said, especially given her sister’s version of the illness. “What you’re dealing with isn’t bipolar in the usual sense of that word,” I emphasized. “It’s like we’re just borrowing the term to throw light on your symptoms. So let me suggest a couple of treatment options that I think might help the depression you’re in now, lessen the chances of going into more depressions later, and stop this painful cycle you’re in, where you feel a little over-revved, and then drop down into depression.” She nodded, her eyes welling as I continued. “By using a medication and a nonmedication approach at the same time, we’ll have the best chance at this.”
After running through the pros and cons of the main medication options (which she’d be taking in conjunction with the antidepressant she’d been on for years), Maria picked lamotrigine, a mood stabilizer that has relatively few side effects and no significant long-term risks. We spent the rest of her second visit discussing other key therapeutic components of treatment, three approaches that research has shown to be effective with bipolar clients: a formal program of psychoeducation (which we’d already begun), social rhythm therapy (which helps establish regular patterns of activity and sleep), and bipolar chronotherapy (a bipolar-specific variation of CBT designed to treat insomnia).
From here, a therapist can cherry-pick specific tools most appropriate for a client’s particular needs. In Maria’s case, a discussion of her family and work relationships—generally strong—convinced me that treatment didn’t need to prioritize interpersonal issues. Her prior therapists had helped her recognize her automatic negative thoughts, such as her tendency to ruminate about perceived slights, and she told me that the mindfulness techniques she’d learned from them usually helped her a little from day to day. What stood out were her difficulties with sleep. For clients with bipolarity, sleep deprivation can induce hypomanic and manic symptoms, while too much sleep can worsen depression. So my initial intervention was a technique from bipolar chronotherapy called dark therapy.
“I can lie awake for hours if I go to bed at 10 p.m.,” Maria told me. “So I just stay up until I’m really tired, which is around 1 or 2 a.m. But then a few hours later, I’m wide awake again. About 4 a.m., I finally get back to sleep and then the alarm goes off at 7.”
Spinning my laptop around, I presented her with graph from a research subject that shows severe, rapid-cycling bipolar disorder coming under complete and sustained control with dark therapy, and with no medications at all. Most clients are usually intrigued when they see this, as Maria was. But within moments of hearing the strict regimen used to achieve this impressive outcome, her face fell.
“Are you kidding me?” she gasped. “I can’t do 16 hours of complete darkness every night, from 6 p.m. to 8 a.m. I have kids!” I explained that the patient in this research approach on the graph improved quickly and then dropped to 10 hours of “enforced darkness,” from 10 p.m. to 8 a.m. But even this regimen struck her as too draconian. So when I told her that there’s a workaround to make the process easier, her relief was palpable.
“Research has shown that all wavelengths of light—blue, green, yellow, red—aren’t created equal,” I explained. “Only one sets circadian rhythm: blue. So blocking blue light creates the equivalent of circadian darkness.”
Maria’s eyes lit up. “Yeah, I think I read something about that!” she exclaimed. But she hadn’t heard how simple it is—a $9 pair of amber-tinted safety glasses can prevent blue light from reaching her retina, denying her brain the signal that says it’s daytime. So she could experience an artificial nighttime while still staying up to read a book or play games with her family. Using the amber lenses meant she didn’t have to turn off the lights at 6 p.m. “So what’s the plan?” she asked.
I’ve learned not to push my luck here. Most people can’t wear these things for more than two hours. So I instructed Maria to put them on about 8:30 p.m. and take them off when all the lights in the house were out, shooting for a bedtime around 10:30 p.m. I went on to warn her, “The amber lenses aren’t magic. They don’t work for everyone. And moving your bedtime earlier won’t happen right away: you’ll make the change gradually. But it’s an important ingredient in developing a more regular pattern of sleep.”
So Maria left our second visit with a prescription for lamotrigine, a pair of amber lenses (we sell them at cost at our front desk), a set of instructions for each, and the hope that these interventions would help her sleep better and alleviate her current depression. I asked her to come back in two weeks so we could evaluate how she was doing.
That’s How the Light Gets In
When Maria returned to my office, she readily admitted that she hadn’t worn the lenses every night. “But when I do wear them,” she said, “I fall asleep earlier, so I’m not up so late anymore. But I’m still having a really hard time getting up in the morning.”
After empathizing with the frustration of a slow start, I added one more ingredient from chronotherapy. “Maria, have you’ve heard of light therapy?”
“Yeah, a friend of mine gave me her light box to try,” she said. “But it was weird. I think it might actually have made me worse, more anxious and irritable.”
Unfortunately, this is a common reaction to light therapy among bipolar patients. Just like a conventional antidepressant, light boxes can induce manic symptoms, often leaving clients in a bipolar mixed state: overenergized, agitated, and unable to concentrate. But there’s a simpler, cheaper element of the chronotherapy toolkit that doesn’t carry this risk: a dawn simulator. Effectively the converse of the amber lenses, these devices turn on a light gradually over 30 minutes in the morning. “The light will reach your brain through your eyelid and say, ‘It’s moorning.
Time to get up,’” I explained. “It’s much simpler than a light box, which requires sitting for 30 minutes. With a simulator, by the time you wake up, treatment is done. It should make waking up easier.” Because Maria had a smartphone, I invited her to download a dawn-simulator app right there in my office. At my suggestion, she picked one called Lichtwecker.
At this point, Maria and I reviewed treatment so far, confirming that she was making use of the amber lenses to try to move her bedtime earlier as much as possible, experiencing no difficulties with lamotrigine, and planning to add the dawn simulator to continue to work toward a more regular pattern of bedtime and risetime.
At our next appointment, Maria made eye contact with me immediately—a first. “Doc,” she said, “I can hardly believe it. I’m definitely getting better.” As she described her improvement—waking up with some energy, having a little more patience with her kids—I found myself relieved. It was too early to expect much change in her day-to-day functioning, such as reaching out to friends or getting more done at home, but we both felt encouraged by movement in the right direction. As Maria talked of feeling a little more in control of her life, her eyes shone. Then, briefly, darkness swept over her face.
Guessing what might have happened, I leaned forward in my chair. “I imagine it’s frightening at the same time, this improvement,” I said softly. “You may be thinking, What if it doesn’t stick? Does that feel right?” Maria looked up, biting her lip. “I’ve been through so much depression, for so long, that I haven’t let myself even wish for feeling normal. Now it seems possible again, and I’m not sure I’m ready for it.” She dropped her head and her voice became so low that I could barely catch what she was saying. “I don’t want to watch myself crash again. I don’t think I can bear it. And I don’t want to put my family through that again.”
As I expressed empathy for Maria’s fears, I was careful not to express too much of my own optimism. She needed to allow hope to return at her own pace. After all, I could do harm if I encouraged her too much and then things went sour. Just as I contain anger when a client’s demands feel inappropriate, I have to manage my hopefulness in this situation.
Over the next several visits, Maria’s mood improvement became more certain and solid. “I’m starting to do stuff with my family again, and it’s so great. One of my friends at work even told me, ‘You’re coming back!’ But the anxiety is still there a little.”
I wondered whether Maria’s improvement, however tenuous, presented an opportunity to consider removing a med. Maria was still on citalopram, the SSRI antidepressant she’d taken for years. Because antidepressants of any type can induce mixed states, and mixed states can trigger an over-energized anxiety, there was a chance that tapering off her citalopram could reduce her anxiety. But it was a gamble, because she was still somewhat depressed. Without her antidepressant, she might slide backward. However, I was now seeing another part of Maria—her gutsy side. “Let’s get going with the taper,” she said, her voice carrying a new note of authority.
“Let’s do it,” I agreed. “But we’ll need to go slowly.” I explained that while many people can taper off an antidepressant over a few weeks, those with bipolar disorders should go much more slowly, unless their manic symptoms are severe. Maria’s shoulders slumped and her voice went flat. “This is going to take forever,” she muttered. So we negotiated a compromise: she’d start out on the faster side (off in two months), but slow down if the first few steps were rough.
And they were rough all right. Even reducing 10 mg of citalopram by one quarter, the smallest step-down one can easily engineer, restarted some of Maria’s old depression. “I just lose the ability to see anything positive,” she reported. “Little stuff, like misplacing my phone or my husband being short with me, sends me into a horrible fit of tears that it’s hard to come back from.” Luckily, this reaction eased up after a few days.
Six months into our work together, Maria was no longer fearful that she’d plunge back into deep depression. “I’m really diligent about my bedtime and risetime: I even get up at the same time on weekends,” she told me. “If I feel a little revved up in the evening, I put the amber lenses on again.” To cement her circadian rhythm, she’d added a regular walk first thing in the morning. “I make myself do this no matter what. When I stopped for a few weeks, I could see myself start to slide.” She shook her head at the memory. “That freaked me out!”
As Maria solidified her gains, we started to meet monthly, until I felt Maria was ready to go it alone for a longer period of time. “You’ve made a lot of progress,” I said. “How would you feel about meeting every six months?” She thought about it for a moment. “I’m fine with that,” she said, “because if I have anything more than a little slip, I know what to do. I’ll be right back here.” Six months later, she arrived in my office radiating a quiet vitality. She told me of a promotion at work and showed me a few photos of her kids playing flag football. With her mood stable and her anxiety much reduced, neither Maria nor I could identify a clear target for further psychotherapy.
Walking the Line
Maria’s story illustrates a number of things. First, some clients with anxious depression actually have bipolar disorder. Of course, there are the risks in taking medications (other than lamotrigine) for bipolar disorder, most notably the major side effects of lithium, carbamazepine, and the atypical antipsychotics. Yet we need to make sure not to miss the opportunity to help people who are on the bipolar spectrum but whose symptoms tend to be overlooked. Many of these individuals spend years in therapy that may provide support but fails to get at the root of the problem: mood or energy cycling. Often those clients are even treated with antidepressants that may make things worse.
Second, Maria reminds us that hope is a double-edged sword. Without it, depression can worsen, and some clients may become suicidal. But for people who’ve tried long and hard to lower their expectations for emotional health, hope can be frightening—and dashed hopes can carry significant risk. Thus, therapists must be aware of their own wishes for the client and manage it in treatment as it shifts over time, with luck, steadily increasing even in the face of setbacks, as in Maria’s case.
Last, we see that bipolar disorder is no longer managed with medications alone, since several well-researched psychotherapies have been shown to improve outcomes. Among these is psychoeducation, starting with basic information about the condition that counters the stigma associated with bipolar illness, and then progressing to more complex issues, such as the possibility of a mixed state. All information is tailored to the client’s learning style and capacities. Chronotherapy techniques help shift and cement circadian rhythm—a mood-stabilizer unto itself. These and other bipolar-specific therapy techniques that can be easily incorporated into a therapist’s toolkit are powerful interventions, which can help our clients gradually reclaim their rightful, balanced place in the world.
By Frank Anderson
Making the correct diagnosis for bipolar disorder is complicated, especially since many other diagnoses share the same features, such as mood variability, anxiety, depression, increased activation, and grandiosity. Getting the diagnosis right isn’t just an academic issue, because, as James Phelps points out in his case study, many of the medications (mostly antidepressants) that treat depression, PTSD, and anxiety can make bipolar symptoms much worse, by flipping them into a mania. To make things even more complicated, the DSM-5 has six different categories under the bipolar umbrella, which include bipolar I, bipolar II, and cyclothymic disorder (the main three), plus substance/medication-induced bipolar, bipolar due to another medical condition, and unspecified bipolar. All these variations point to the limitations of viewing bipolar clients as displaying consistent features of a single disorder, when in fact, a more helpful way of understanding these clients might be to reassign them to more than one diagnostic category.
Phelps addresses the increasingly common practice of considering bipolar disorder a spectrum disorder, much as is done with dissociative disorders, from less to more severe. This seems fine as long as we’re focusing on the intensity and duration of only one symptom, like mania or dissociation. But when you add in other dimensions, like the duration and intensity of mania, depression, and/or mixed states, the essence of the diagnosis becomes even more difficult to capture.
Nonetheless, I agree with Phelps that psychotherapy should be a vital part of the overall treatment for bipolar disorder, with attention to psychoeducation as another key component. However, if the condition is to be successfully managed, therapy needs to go a step further, looking deeper into the roots of what triggers a manic or depressive episode for each individual. Beyond learning about the importance of medication compliance and good self-care—such as sleep, exercise, diet, and minimal substance use—clients need to understand their particular trigger points and vulnerabilities. For example, understanding their trauma histories has enabled me to successfully treat many bipolar clients by pinpointing how their episodes were triggered by specific painful memories from the past. Similarly, recognizing how a current loss triggered unresolved grief can be a key to effective treatment, as well as a way of helping clients develop their own capacity to prevent future episodes.
Phelps emphasizes the role of complementary treatments, but I’d caution against using alternative treatments as the sole approach to the disorder. I can see the rationale for using chronotherapy (dark/light therapy) in this case, as part of Maria’s treatment, since many bipolar clients are exquisitely sensitive to seasonal variabilities, as well as interruptions in their sleep/wake cycles. But it’s important to recognize that proven medical interventions such as ECT, mood stabilizers, and atypical neuroleptics that can help stabilize nerve membranes and decrease brain kindling remain the best practices in working with this still poorly understood disorder.
Illustration © Sally Wern Comport
James Phelps, MD, specializes in complex mood and anxiety problems. He has focused on teaching about non-manic versions of bipolar disorder for over 10 years. He is the author of Why Am I Still Depressed?: Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorders (McGraw-Hill, 2006). He authored revisions of the diagnostic criteria for bipolar spectrum disorders for the International Society for Bipolar Disorders. He has published multiple articles and reviews for peer-reviewed journals, including the Journal of Affective Disorders and Chronobiology International. He was recently named Bipolar Disorders section editor for Psychiatric Times. He has received numerous awards for his teaching including Teacher of the Year awards from both the Psychiatry and Family Medicine departments at the University of New Mexico, and from his current hospital’s residency program.
Frank Anderson, MD, a psychiatrist and psychotherapist in Concord, MA, specializes in the treatment of trauma and dissociation. A lead trainer at the IFS Institute, he’s affiliated with Bessel van der Kolk’s Trauma Center and advises the International Association of Trauma Professionals. His most recent book is Transcending Trauma: Healing Complex PTSD with Internal Family Systems.