Featuring Major Depressive Disorder, Substance Use Disorder, nihilistic delusions, and Bipolar Type II
The morning alarm rings. You dismiss it, stay in bed, and stare at the ceiling. Dread and melancholy begin to invade wakefulness with every passing moment (symptom #1: inexplicable sadness). Your body stays still as your mood tends to spiral into hopelessness (symptom # 2: feelings of hopelessness); the negative thoughts and anxiety (symptom #3: anxiety) about yourself, about your future and present and past weigh so heavily on your conscience, your energy level already low and your body overtaken by an inexplicable fatigue. Your brain is in a fog (symptom #4: trouble concentrating) or tuned in to an inner, repetitive soliloquy of negative thoughts and self-talk (symptom #5: feedback loop of negative thoughts). You cannot find the strength or motivation to move beyond the promise of unconsciousness offered by staying in bed. Your instinct is to shut down, go back to sleep. You stop caring or even forget if you had work that day or an appointment with friends (symptom #9: apathy). You want to avoid human interaction (symptom # 6: social isolation). None of the prospects of the day, even if previously enjoyable or urgent, can muster enough willpower (symptom #6: anhedonia) to override the hypersomnia (symptom # 8: tendency towards vegetative states or sleep) that dominates your impulses. You feel worthless and tired and your mind wants to become impervious to emotions if it is not already. Sometimes, you will feel like you are a passive, numb spectator of your life or feel like your experiences are not real, which are characteristics of a symptom called depersonalization (#8). The day could most likely end up lost, meetings or classes missed; phone calls or texts ignored. You succumb to slumber once more, but when you wake the mental fog still coats your experience, so you forget a lot of the things that happen when you are awake (symptom #10: memory loss); recollections while in this state tend to become a blur.
It’s possible you are experiencing an episode of a pernicious and increasingly diagnosed illness: Major Depressive Disorder. *
My depressive symptoms first began to manifest around the age of 16, which was a solitary and profoundly introspective time in my life. But I somehow managed to survive and thrive academically, driven by my ambition to pursue a PhD in Neuroscience, until I finished undergraduate. The last year of my undergraduate was marked by the worst and most traumatic period in a relationship that had become toxic and co-dependent; the effects made more lasting and destructive by my gradually increasing alcohol abuse. On the day of my graduation, a day where I had much right to celebrate, I had a nervous breakdown in front of my mother. I was overwhelmed with hopelessness, faithlessness, and sadness for myself. It was the first time I had shown either of my parents that I felt such despairing and negative emotions about myself. We concluded that, during my upcoming gap year, I would seek intensive therapy. At that point I felt I would try anything to start climbing out of the melancholic hole I felt trapped in, so I agreed to begin intensive outpatient treatment, which focused on treating my depression rather than the substance use disorder I had developed. Naturally, the psychiatrist and therapist assigned to me diagnosed me with Major Depressive Disorder at age 21. I was treated for this diagnosis with the standard regimen of exercise, therapy, and antidepressants until my third year of graduate school as a Neuroscience PhD student, when the first notion arose that we may had overlooked a key symptom could mean I had possibly been misdiagnosed.
Graduate school introduced a significant number of unprecedented pressures in my life and I found myself cycling through moods in an erratic fashion and with such an intensity as I had never before experienced in my life, compounded by a return to increasing alcohol abuse. The first discussion I had about the possibility I had been misdiagnosed was with my mother (who has a PhD in psychology and enough knowledge of my behavior across the years so as to substantiate a longitudinal case study of sorts). After consulting the DSM-5, she had begun to wonder if hypomania was a symptom we had not considered. Given that I had only sought professional treatment due to the severity of my depressive episode, I had dismissed the periods of high-spirited creativity, restlessness, and impulsivity that I have experienced in the past as traits of a high-functioning depressive. She urged me to talk to my psychiatrist about the possibility that my mood disorder symptoms were indicative of a Bipolar Type II diagnosis. I was initially apprehensive of these ideas, given that I was so used to understanding myself as a patient of Major Depressive Disorder. I had come to understand myself through the lens of this diagnosis. But, after reading up on Bipolar disorder and, upon closer retrospection, I slowly started recognizing that perhaps I had experienced what could accurately be characterized as hypomanic episodes. Another realization was that the unstable epochs (I would go from low to high moods over and over in the span of one day) fit in with the description of rapid cycling (another symptom of Bipolar II).
To confirm this theory, I first had to remove my substance abuse from the equation. Towards the end of my third year at graduate school, my unstable moods were followed by another major depressive episode, no doubt exacerbated by my regular abuse of a depressant. Co-morbidity of mood disorders and substance abuse is common. Moreover, it is possible that the substance abuse disorder I had developed was one of the main causes of the intensified symptoms of a mood disorder that seemed to align more with a Bipolar II diagnosis. It has been shown that it is possible to develop or trigger mood disorders due to the chemical imbalances induced by substance abuse. To address my addiction, I took a 3 month-long leave of absence from grad school and went through intensive outpatient and inpatient substance abuse treatment. Sobering up after years of regular substance use took a lot of effort, time, support, medication, and therapy. But by removing alcohol and other substances out of the equation, I started to feel much better: I felt like my medications were working, my mood was more or less stabilized, and I felt hopeful that most of the symptoms driving my erratic, unstable moods and behavior had mainly been triggered by my substance use disorder.
With improved self-awareness, more tools in my self-care kit, and a clearer mind, I returned to graduate school, expecting a slow transition back into working on my thesis project. To my misfortune, that is when the pandemic began. The shut-down of my institution completely derailed my transitioning plan and introduced major setbacks in my work, even forcing me to reduce the scope of my thesis project. I was quite demoralized. Moreover, I found myself still experiencing rapid cycling on occasion. Through self-tracking and journaling, I discovered that my moods followed a cyclic pattern: I would feel stable for some days, interspersed with days where I felt almost manic (i.e. million thoughts an hour, very impulsive, illogical and delusional thinking, productive, euphoric, restless, insomniac) for periods which lasted a day, give or take. And then I would slip into depressed states, for periods which lasted almost always more than 2 days. This is when my psychiatrist decided to officially diagnose me with Bipolar II and to begin the shift in treatment by adding mood stabilizers to my medications (which at this point included antidepressants and anti-craving meds to help curve urges to use).
Thus, my Major Depressive Disorder diagnosis evolved into a Bipolar Type II diagnosis, supported by a re-assessment of my symptoms while sober and shaky evidence of possible genetic predisposition (my grandfather on my father’s side was suspected to be Bipolar, but was never clinically diagnosed). As someone who has an academic background in biology/neuroscience and is actively pursuing a PhD in the study of the nervous system, I can easily think about my mental illness in terms of physiological causes. I believe I had a biological predisposition to develop a mood disorder, given that I first began to experience depressive symptoms and possibly hypomania before I developed a substance use disorder. Trauma, stress, and substance abuse served to trigger, exacerbate and, in a sense, empower my mood disorder. You would think that someone with my knowledge and awareness of the consequences of substance abuse and poor self-care practices would know better and act to protect my mental health at all cost. But when I was 16th, I became the victim of nihilistic delusions that have heavily influenced my perspective up until this year. My conviction in the inherent meaninglessness of existence coupled with periods of impulsivity and poor judgement made me develop an attitude of disdain towards the knowledge I had and kept consuming. My modus operandi of “do what you want when you want; all is meaningless after all” justified and even encouraged my recklessness. In fact, my nihilism has probably been one of my mental illness’s biggest allies. But I have been fortunate that the ambitions and plans I’d developed in my youth were enough to keep me moving, that I have the resources to receive professional help and clinical treatment, and that I’m surrounded by people who have always cared and supported me through any struggle.
Every day I wake up with an untreated illness that requires a combination of medication, therapy, exercise, sobriety, meditation, self-monitoring, social support, healthy sleep/eating habits, and more to keep in check. This is a lifelong deal. And, while I have accepted my fate, I am far from mastering my treatment. To conclude this protracted history, I want to offer some advice to those who also struggle with a pervasive mental illness:
- Learn as much as you can about your symptoms, your diagnosis, and their causes. Humans understand in order to manipulate, to gain control; knowledge of your mental illness is one of the best ways to remain self-aware and to design a strategy to treat your illness.
- Seek professional help. Therapy is a great way to learn about your mental illness, receive social support, as well as a key resource in developing tools to cope and treat your illness.
- Self-monitor your daily states/symptoms. This is an essential practice to keep track of the manifestation of your mental illness and to maintain insight into your psychological well-being.
- Exercise and/or meditate. It is almost miraculous how beneficial exercise has been to regulate my mood and meditation is another superb tool to develop self-awareness and self-control.
- Establish a support network, socialize regularly, and be open about your mental illness (if you feel comfortable enough). Isolation will only empower your illness. Talking about your experience, feelings, inner conflicts is a way to unburden yourself and to process difficult emotions. It can also help encourage others who are also struggling.
- Persevere. It is difficult and sometimes may seem like a daily struggle but believe that you can overcome your mental illness; there are so many tools and practices at your disposal. And you are not alone.
* Disclaimer: the previous description is based mainly on my personal experiences of major depressive episodes, but symptoms vary across individuals. Insomnia, lack or excessive appetite, suicidality, agitation, excessive crying, irritability, restlessness, mood swings: all of these are symptoms associated with major depressive disorder.