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Dr. Robert,

Is it possible to have both a unipolar and bipolar form of depression?

I wonder this because I think that I may have cyclothymic depression,

but I can't be sure. I'm a 19 year old female. I often get deeply

depressed and even suicidal. This may last for several weeks, then I

generally start to feel better. Sometimes I feel a lot better, though

this may simply be because of comparison, as the greatness of it seems

to fade pretty fast.

I've read the criteria for a so called hypomanic episode, and I can't

say that I have ever experienced one in which I met all of the

criteria. For instance, I might feel like a great weight has been

lifted and I suddenly have more energy, and am more sociable, and

optimistic. Sometimes I have trouble falling asleep because a constant

flow of thoughts is going through my mind. But, I can't say that I

have ever felt a sufficient increase in self-esteem (my self-esteem

has always been low)- certainly not grandiosity- or motivation. These

periods never last for more than a day or two, if even that, before I

begin to slide back into my usual depression. The criteria for such an

episode seems to be an extreme version of what I experience,

So, I wonder if it is possible that I also have dysthymic depression

and that it would lower the effects of my "hypomanic episodes" (if

that makes sense.) This is just wild speculation, of course.

Depression and suicidal thoughts are nothing new to me. I've struggled

with them all my life, which is why I feel I might also have dysthymic


I do seem cycle through levels of depression and happiness (or

markedly less depression). Sometimes this is tied to my menstrual

cycle and sometimes not. Also, as a result of this cycling, I have

come to find a certain comfort in my sadness. It is something that I

can rely on, and even when I am "happy" I'm not really, because I fear

falling back into depression (which I always do) and even come to miss

it. Misery, has become for me, a true companion.

I hope you will answer. I know you are swamped with questions, but I

am hardly qualified to figure this out. That's why I came to you.


ask dr-robert

Hello, Rachel--

I assume that you have found out about the diagnostic criteria to which you refer by reading the DSM (The Diagnostic and Statistical Manual). That book, I should explain for other visitors, lists a variety of mental and emotional disorders, along with lists of criteria which the book says psychologists and other mental health professionals should use to decide if a particular patient "has" the ailment or not. For example, when Rachel refers to "dysthymic depression," she is referring to one entry in the DSM, the entry for so-called "Dysthymic Disorder," which the DSM says is a mood disorder "characterized by an overwhelming yet chronic state of depression, exhibited by a depressed mood for most of the days, for more days than not, for at least 2 years." (Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association. 1994.)

Further, "The person who suffers from this disorder must not have gone for more than 2 months without experiencing two or more of the following symptoms:

poor appetite or overeating

insomnia or hypersomnia

low energy or fatigue

low self-esteem

poor concentration or difficulty making decisions

feelings of hopelessness

"In addition, no Major Depressive Episode has been present during the first two years (or one year in children and adolescents) and there has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder. Further, the symptoms cannot be due to the direct physiological effects of a the use or abuse of a substance such as alcohol, drugs or medication or a general medical condition. The symptoms must also cause significant distress or impairment in social, occupational, educational or other important areas of functioning."

ask dr-robert

Now, Rachel, you seem to be asking if perhaps you "have" more than one disorder, so that the effects of one might be mitigating the effects of the other. My answer may surprise you, and some mental health workers will disagree with this, but, in my view, it does not matter at all. Let me explain.

The categories laid out in the DSM are used for diagnosis, but that is mostly for the convenience of insurance companies who have to decide whether or not to pay for treatment, and also to enable communication between the doctors and others who have to care for patients whom they may not know. In other words, not knowing a patient, one of these workers can read a file containing a diagnosis and get a rough idea of what is troubling the patient. But a DSM diagnosis does not explain anything about the patient, or about his or her life, and certainly does not explain at all what would be best for the patient, or how the patient must be treated. Despite all the talk about brain chemistry, what causes mood disorders is neither known nor understood. The diagnostic categories are simply a rough statistical (as in Diagnostic and Statistical Manual) breakdown of signs and symptoms which can be used roughly to differentiate one mental or emotional disease state from another, more for convenience than for anything else. A diagnosis is not a treatment plan. And, in fact, the DSM says nothing about treatment, nor anything about etiology (causes) either.

To answer your specific question: by definition (the DSM definition, I mean) no one can meet the criteria for both unipolar and bipolar depression because by definition bipolar mood disorder is characterized by mania, usually alternating with some level of depression, while, by definition, unipolar depressive mood disorder does not alternate with any kind of mania or elevated mood. But, as I say, all that does not matter because these diagnoses deal only with observed average statistics, not with individuals.

When treating an individual, in my opinion, making a diagnosis is rather unimportant compared to learning the details of that person's life and the struggles which have brought that person to the need for professional treatment. When you, for example, tell me that misery has become a companion, I think I have an idea of what you mean, and if you were my patient, I would be far more interested in finding out more about that along with your other ways of dealing with your unstable moods, than in deciding if you meet the criteria for hypomania, dysthymia, or any other DSM category. I might or might not make a diagnosis, but if I did, I would not rely upon it as a way of understanding you. Understanding you would be a ongoing project while the diagnosis—assuming I even made one—would simply be a convenience I might need for one purpose (insurance, for example) or another.

In other words, the various so-called mental disorders and their diagnostic criteria belong to a system of generalities, while your particular struggles, mood changes, your suffering, and how you manage to live your life while depressed--all that--are the specifics, which, in my view, are what really determines what kind of treatment might help, and what I might be able to do to help with that treatment.

I hope I have made this clear, Rachel. If so, perhaps you might think less about the DSM its generalities, and more about your own unique life and its specifics.

Be well.

ask dr-robert

Dr. Robert,

Thank you so much for replying. I see what you mean about the DSM. I

shouldn't try to define myself by what DSM categories I fit into. I

guess I just wanted to understand what's wrong with me, to have a

reason behind the way I am. Sometimes my life, present and past, seem

like a jumbled mess. Things seem to be falling apart, and they always

were. Even my memories elude me. So, it seems hopeless to try to

organize my mess of a life to assess what my problem is and how to

begin fixing it. To me a diagnosis seemed the next best thing. I will

take what you said to heart, a diagnosis is not really what's

important. Thanks for your help.



How wonderful that you understood this. I know both from your letter and from my professional experience with mood disorders how challenging all this is for you, and how hopeless you must feel at times. Nevertheless, I also heard in your letter an intelligence and a strength which I believe will serve you better if you stop trying to reason this out--there is no reason: things just are the way they are (or as they say in Zen, "In the garden, tall bamboo, short bamboo")--and simply try see yourself from moment to moment as you are.

You mentioned having periods of feeling good. I doubt that those periods are mania but probably more just normalcy. When you are feeling down, try to remember that there will be relief. When you are not feeling down, enjoy.

You are young, and I feel for you and the difficulties you face. I hope you are getting good help with therapy and medication.


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