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Dr. Mark
Dr. Mark, Psychotherapist
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Experience:  Dr. Mark is a PhD in psychology in private practice
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In bipolar 1 disorder will one symptom always happen before

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In bipolar 1 disorder will one symptom always happen before another. Will there always be mania first followed by depression or depression first leading to mania or can it vary. If it can vary is it more likely that one symptom would appear first?

Hi! This is an excellent clinical question.

In my experience and training, BD1 is not strictly sequential. There are actually 3 "stages" or "phases" that we can speak of: there is the depressive deep dark black hole that can be very oppressive; there is the other pole of the manic phase where there are grandiose plans, endless energy and eventually delusion; there is the third phase, which is the stable middle stage, neither depression nor mania.

Now, each of these three stages or phases is not static. Each phase has gradations of severity and sometimes slightly different manifestations. So, for example, in the depressive dark hole, the person can truly feel like he's in a deep pit and can't even see his way out or any "sunlight" at all. But sometimes it isn't that severe; he feels sad and lethargic. Or he may feel blue and irritable. See how it can be different manifestations and severity?

The goal of treatment is always to get the person back to that middle stage: what we call stability. The medications try to do that by regulating brain chemical inputs. This is a bit imprecise because it can make the person feel like he can't "feel" or it's not really "him" going through the day. But the goal of the meds is to not let those extremes form. They, of course, are not 100% able to regulate the person's moods.

This is also, then, the goal of psychotherapy that is specific to BD, like Copeland's WRAP program I wrote to you about earlier. The goal is to have the person be able to identify the early warning signs of his mood beginning to spike up above "normal" range or down below "normal". I like to use the analogy of a car for this:

Most people are like cars with automatic transmission. They tool around the day going from a little sad and then they feel a little glad and if they get to too high a gear, the emotional transmission just automatically sends them back to a lower gear and if the low gets too low, the transmission clicks into a higher gear. Rarely are they thinking about it. They are usually within their normal range.

Those with BD are like a car with a manual transmission. They start having a racing mood and unless they downshift manually, they're going to be out of control soon until they can't maintain that and they cycle down and then get too far down, etc. So they have to continually use the clutch and manually adjust the emotional gear.

There is no specific sequence that these mood cycles take. A person can have a number of depressive episodes before there will be a manic one. Or vice versa (less common). Life stressors can trigger episodes; hormonal changes; and other factors we don't yet understand fully or know about.

Okay, I wish you the very best!

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