1) Changes in Activity or Energy Levels
Most of these symptoms are fairly easy for a patient or others to notice. Examples of each are given to help you or family, friends and others to recognize when loss of energy and decreased activity may signal the onset or presence of a bipolar depressive episode.
- Decreased Energy – Nothing mysterious here; it is as simple as consistently not having as much get-up-and-go as you had last week or last month. A month ago, you still felt good enough after work most nights to go out to a movie or to dinner. Now, you run out of steam every day at 4 p.m. Family members, friends or coworkers may notice that you are flagging earlier in the day or that you are choosing, for example, to read rather than exercise in the evenings.
- Fatigue – This is the next stage after decreased energy. Depression can cause physical fatigue. Sleep becomes unrefreshing, so that you are tired even when you get up in the morning. You feel tired during the day. You may perk up at some point, but the moment you get home you feel as if you’ve been run over by a train. You don’t know why you are so tired, either. Family members/friends see you yawning, hear you saying how tired you are, notice that your posture is slumping or that you’re stretching during the day. They hear you sighing and notice that you are working more slowly and hesitantly.
- Lethargy – Lethargy is a more serious symptom. It is defined as “abnormal drowsiness or stupor; a torpid, apathetic state.” In terms of depression, both of these definitions can apply. Someone in a depressive episode may be unusually drowsy. Or a person can be what is more commonly thought of as lethargic – spending hours just sitting in a chair. The person may not be in a totally unresponsive, catatonic state, but is simply uninterested in doing anything, and feeling physically and mentally heavy.
This symptom is one that would interfere with your normal daily responsibilities, so your loved ones, friends or coworkers would be able to identify it with little difficulty, as should you.
- Diminished Activity – This may be a result of decreased energy, fatigue and lethargy, or it may occur independently of those symptoms. In either circumstance, you and those around you should notice if your level of activity begins to drop – for example, if you normally do the laundry and simply begin to leave it undone or if you go to a diet group three times a week and then just stop going.
- Insomnia or Hypersomnia – Insomnia means having trouble sleeping. It’s a common symptom of depression: lying awake worrying, unable to get comfortable, feeling tense or just having your mind race. Hypersomnia is just the opposite: sleeping too much. People in depressive episodes have been known to sleep more than 20 hours a day.
Insomnia may or may not affect your daily routine. Because many factors can cause insomnia, it may have to go on for a while or occur along with other symptoms for you to realize that it is a depressive symptom. Hypersomnia, on the other hand, stands out immediately and is a signal for a call to your psychiatrist.
- Loss of Interest in Pleasurable Activities – The name of this symptom describes it well. You normally love to go bowling but start turning down every invitation. Here are a couple of fictional examples: Mary’s a fanatical gardener, but this spring she isn’t out there with her trowel and plants the way she usually is. Rick has season tickets to the New York Mets baseball team, but he’s been staying home. When you ask him why he missed the last game, he just shrugs and says, “I didn’t feel like going.” This symptom may be easier for others to spot than for the person who is going through it.
- Social Withdrawal – This symptom is easy to describe, but it may be hard to notice, depending on whether the bipolar person’s personality between episodes is more outgoing or reserved, more “party animal” or more “quiet evening alone with a book.” Someone who is naturally solitary may become more social during a manic or hypomanic episode, then withdraw too far during depression. But since this person is known for being something of a “loner,” no one may realize that this time the withdrawal is more serious than usual.
Other changes in activity or energy not listed may also occur, but the ones above are those most commonly associated with bipolar depression.
2) Physical Symptoms
Anyone who thinks depression is all in one’s head has never been depressed – or never realized it. Depression affects more than the mind – it has significant physical symptoms as well. Some of these were discussed in Part 1 of this series, Decreased Energy or Activity in Bipolar Depression. In this article we discuss the second group of symptoms listed in Red Flags to Depression.
Bipolar Depression: Physical Symptoms
- Unexplained Aches and Pains
One theory about why depression causes body aches is that depressed people are often:
- Physically stressed due to sleep deprivation (from insomnia); or
- Just as physically stressed, even though they are sleeping as much as or more than normal, because the sleep is not restful.
Unrestful sleep is a significant component of both chronic fatigue syndrome (also called myalgic encephalopathy) and fibromyalgia, two conditions characterized by moderate to severe body aches. It isn’t surprising, therefore, that there is a close association between fibromyalgia and depression/anxiety.
In addition, depressed people often have higher than normal levels of the hormone cortisol, often known as the “stress hormone.” Too much cortisol is often seen in patients with chronic pain, though a cause-and-effect relationship has not been established.
- Weight Loss or Gain
- Decreased or Increased Appetite
Loss of appetite is common with depression – but it’s also common for depressed people to turn to food for solace. Thus, both weight loss and weight gain can be symptoms of a depressive episode.
One reason why people turn to food – and particularly fattening foods – when depressed is that carbohydrates raise the brain’s level of serotonin, one of the neurotransmitters that are associated with depression when levels are too low. Also, an excess of cortisol is thought to cause the body to store fat inappropriately.
- Psychomotor Agitation or Retardation
Psychomotor agitation is an increase in activity caused by mental rather than physical tension. Typical behaviors seen with this symptom include pacing, wringing hands, finger- or foot-tapping, and other similar restless actions.
Psychomotor retardation refers to a slowing of both thought and physical activities. Regular tasks such as brushing teeth or eating may be performed in an unusually slow and/or deliberate manner.
3) Difficult Moods in Bipolar Depression
Like the other symptoms of bipolar depression, the difficult moods listed here — irritability, anger, worry/anxiety, pessimism, indifference, and a tendency to be self-critical — may also be present in major depressive disorder. The difference, of course, is that in bipolar disorder there are also episodes of mania or hypomania.
In addition to the depressed or sad mood and lack of pleasure that are typical of depressive episodes, the below mood states might also indicate depression. To further complicate matters, irritability and anger may also be reflective of manic symptoms as well.
Almost everyone becomes irritable now and then. The reasons are almost without number. A headache, a bad night’s sleep, an upcoming dentist appointment, an unexpected bill — any stressor can bring it on. But when there is no apparent reason why the least little thing becomes an annoyance, and the mood persists for days or weeks, look for depression as the cause.
Anger is irritability pushed to an extreme. In depression, a person may explode over what might otherwise be a mild irritant — or over nothing at all. It may be a brooding anger that comes to a boil over something seemingly harmless. If anger lasts or becomes frightening or violent, seek help for yourself or your loved one as soon as possible.
This may present in a number of ways. For example, a person may seize on a few daily items and worry obsessively about them. Do I have enough sleeping pills? What will we have for dinner? Did I put gas in the car? Another form is responding to every issue with anxiety. I have to call the plumber — what if he can’t come today? I’d better leave early for my appointment in case the traffic is bad. Or it could be a more generalized anxiousness, perhaps accompanied by the racing thoughts that are more commonly associated with mania or hypomania. Anxiety is frequently associated with being indecisive.
Pessimism means taking a negative view of everything. It’s going to be another bad day. Nobody likes me. There’s no point in applying for that job. In the case of depressive pessimism, the negativity is exaggerated all out of proportion with reality: There’s no reason for it to be a bad day, some people do like you, and whether you’re depressed or not, you might have a good chance of landing the job.
Simply put, indifference is not caring. The laundry piles up, the bills aren’t paid, and you don’t care. A friend calls with a problem, and you can only make polite noises or sit and listen silently, the words not really penetrating your shell of indifference. In depression, it isn’t even so much that you don’t care as that you can’t care.
Everyone has flaws — but in this mood, your flaws seem magnified and you find flaws that aren’t there. “I look tired today” becomes I’m ugly. “I’ve made a mistake in balancing the checkbook” becomes I’m an idiot with numbers. Forgot to feed the cat? I’m worthless. If you hear yourself or your bipolar loved one frequently saying overly negative things about him or herself, let it be a warning signal to you that depression is taking over.
It’s important to know the characteristics of depression so that you can identify them as symptoms of a depressive episode when they occur, whether in yourself or in someone for whom you care or are responsible. Recognizing the symptoms as signs of depression can sometimes help to alleviate them; knowing what to look for means you can seek help that much sooner.
4) Changes in Cognitive Skills
Cognitive skills are the patterns of thinking that allow us to perform tasks. They include processing speed, short-term and long-term memory, concentration and decision making. Problems with these skills can have a profound effect on behavior. In fact, these symptoms – difficulty concentrating, indecision, memory problems and disorganization – may be the among the ones first noticed by co-workers and supervisors because of the way they affect on-the-job performance.
- Inability to Concentrate
This can take two forms. It may be that no matter how hard you try, you simply cannot focus – on the task at hand, on a book you’re trying to read, on the lecture you’re attending, on the recipe you’re following. Or it may be that your attention wanders without your being aware of it until someone points it out to you, or you suddenly notice you’ve been staring at the same page of your book for 20 minutes. Both can be embarrassing and frustrating. In either case, the inability to concentrate is an important condition to be noted.
What to wear to work today? Which of three projects has priority? What’s the best day to choose for a doctor’s appointment? What should you make for dinner? In a state of depression, making even simple decisions can become a major undertaking, and more difficult decisions can become impossible. When indecision is accompanied by anxiety, being confronted by the necessity of making a choice can even lead to hysteria. People tend to think of a depressed person as being quiet and withdrawn, but if that person is backed into a corner, it can result in an emotional explosion or collapse.
- Problems with Memory
Memory problems primarily occur as a result of poor focus – that is, because of difficulty concentrating, you simply didn’t hear something that was said to you and so don’t recall it later. But many cognitive processes become slower and less effective in depression, including memory.
Disorganization is not exclusively a symptom of depression, nor is it necessarily a disorder. And it is perfectly possible for a manic or hypomanic person to be unorganized, but in that state such a person isn’t likely to be bothered by it and may, for example, know just where a particular item is in spite of having his belongings in a state of chaos.
As with all the depression symptoms we’ve covered, recognizing these symptoms is a key element in knowing when to get help. For example, if you are always indecisive, even when manic or hypomanic, indecision likely won’t be an identifying characteristic of depression for you – unless you react to it differently depending on your mood. If you can laugh it off when hypomanic, but are filled with anxiety about it when depressed, you have a personal marker for your own depressive episodes.
5) Emotional Pain in Bipolar Depression
Emotional pain isn’t unique to depression. For example, all of the symptoms listed under this heading in Warning Signs of Depression can appear in times of grief. Individual symptoms or a cluster of them may be triggered by other events as well – job loss, divorce, a profound disappointment. If the symptoms continue too long, they may require treatment. But by themselves, these symptoms don’t necessarily indicate the presence of major depression. Let’s take a look at them:
- Prolonged sadness
- Unexplained, uncontrollable crying
- Feelings of guilt
- Feelings of worthlessness
- Loss of self-esteem
These symptoms, especially taken individually, are not unique to clinical depression. Feeling helpless, for example, may be a reasonable initial reaction to a difficult situation.
In bipolar depression, however, a feeling of helplessness is likely to be:
- Combined with other types of emotional pain
- Combined with other types of depressive symptoms
- Prolonged beyond a reasonable time
- More severe than is reasonable
As I said, any one or more of these symptoms could be a common reaction to a traumatic event. But if they don’t get any better after a reasonable amount of time, are increasing in severity or are significantly impacting your functioning, you should seek help. One element that can differentiate bipolar depression from a more expectable emotional reaction, is that in a person suffering from a mood disorder, these symptoms may also occur spontaneously, without any clear triggering stress.
At the same time, any stressful life event – be it sorrowful or even joyous – has the potential to set off a depressive episode in someone with major depression or bipolar disorder. Thus, it is particularly important to monitor someone with a history of depression, mania or hypomania after any kind of major life occurrence, such as divorce or marriage, a death or a birth.
6) Preoccupation with Death
Although the three symptoms listed under this heading – thoughts of death, suicidal ideation, and feeling dead or detached – may sound like different terms for the same thing, they actually are distinct forms of preoccupation with death.
Thoughts of Death
Thinking about death to a marked degree may take the form of imagining oneself dead. For example, a person may envision himself lying in a casket. He may imagine what will happen at his funeral, obsess about what to leave people in a will, and even begin giving away possessions.
“I wish I were dead” is a common phrase that most people utter without meaning, but in a depressed person, the thought becomes fact. I knew a 7-year-old boy who told his mother, “I wish I had never been born, or if I had to be, I had died right away.” Fortunately, his mother wasted no time getting help for her child.
In suicidal ideation, “I wish I were dead” progresses to thoughts of making it happen. A depressed person may be tipped over the edge by a stressful event, or the progress of the illness may be to blame. She may begin thinking of and actually making plans for suicide.
Whether or not the person has a plan in mind for suicide, these thoughts must be taken very seriously. Some of the highest risk factors for completing suicide include history of previous suicide attempts, presence of significant life stressors, and access to firearms.
Feeling Dead or Detached
A person who feels dead or detached experiences a group of symptoms that have been mentioned in some of the previous five articles in this series. They include:
- Loss of interest in pleasurable activities
- Social withdrawal
In addition, the person may feel like he or she is simply an observer of what is going on around him or her. There may be a sensation of “standing behind” oneself and watching what happens.
Bipolar depression is similar to major depression. The depressed bipolar person may be more likely than a person with unipolar depression to have a “mixed” type of depressive episode, including agitation (both mental and physical), irritability, anger and anxiety.
Single symptoms are rarely present. For example, a depressed bipolar person might experience any of the following and have no symptoms of preoccupation with death (group 6):
Thanks to D for this reference.