Was I Misdiagnosed? Unipolar vs. Bipolar Depression

In late summer of last year, I increased my antidepressant, Emsam, from 9 to 12 mg. I was staying in a hotel at the time, and something odd began to happen. I started to hear music when the AC was running.

It is normal for people to hear tunes in the mechanical background noise of fans. It is not a psychotic illness – merely an odd perceptual idiosyncrasy. However, what I experienced was much more complex than any small, lilting buzz I’ve ever heard in a fan before.

The Musical Phenomenon and A Shift in My Mood

I was hearing soundtracks. Vocalists, instruments, the whole nine yards. I couldn’t decipher any lyrics, but there were distinct genres that ranged from pop to broadway to country. It sounded as if the music were coming from a different room, and for a while, I believed it was. But eventually, I began to get suspicious.

I walked around the hotel room, putting my ear to the walls, listening for a change in volume. I opened the door and poked my head into the hallway. I stood on the bed and listened to the ceiling. It was always the same volume. When the AC shut off, so did the song. A different song would start up after a few minutes of the AC running again. Sometimes, a sudden shift in my attention would cause the music to stop, even when the AC continued to run. It became clear to me that what I was hearing was not real, and it disturbed me.

A Mountain Escape

I was about to go to a new location – a trip with my mom to a small, mountain town for some wilderness relaxation. We planned to hike up to a lodge at 11,000 ft above sea level and stay for a few days. The hike up was arduous; it was the hardest hike I’ve ever completed, despite being shorter and with less elevation gain than other hikes I’ve done.

I remember that I wasn’t sleeping well, and my body just refused to cooperate as I forced myself up the trail. I had to stop frequently and lean on my pole, taking gasping breaths. At the lodge that night, I heard phantom hummingbirds zipping all around me as I lay in bed. In the morning, the sound was gone. I was unsettled, but I tried to put the experience out of my mind.

I was testy on that trip. My head was not in a good place, and my mind was filled with overwhelming irritation. I cried a lot. Neither my mom nor I were having a good time, so we left early and headed down the mountain to get a hotel room.

Upon reaching the hotel, a minuscule setback occurred, and it sent me over the edge. In a second, I went from chill to overwhelming, roiling anger. It was like calm seas to tsunami in the blink of an eye. I contained most of this energy, but some escaped in the form of expletives, fist clenching, and undignified, hurried marching on my way to our hotel room.

I am typically a very levelheaded, patient person. I strongly dislike being angry, and when I am, I make every effort not to show it. (Is that unhealthy? Yes.) In that moment at the hotel, I felt completely unhinged.

My dog had never seen me in such a state, so she hid under the table. The sight of her filled me with guilt and self-loathing. I immediately dissolved into dramatic, uncontrollable sobbing, which only frightened my dog even more. I was convinced that she would be afraid of me forever, a consequence for which I wholeheartedly believed I would never forgive myself.

Luckily, dogs are good creatures, and Stella came around once I had composed myself. Composure took a while to reach, but a hot shower helped.

Looking back, I feel like I was not myself from the very start of that trip. The rest of it passed fairly uneventfully, but I continued to hear sounds and music that were not real until a few days after returning home.

She forgave me quickly ❤

I’ve gone back and forth between 9 and 12 mg of Emsam since then, and the musical illusions occur sometimes when I take 12 mg. Sometimes it’s music, an incessant buzzing, or the murmuring sound of a group of people talking far away. Sometimes I can identify the background noise that accompanies it, and other times, it seems to happen on its own.

The Ketamine Incident

A couple weeks after returning from our mountain trip, I had a ketamine infusion that resulted in a bizarre, seemingly manic few days. I wrote a post shortly afterward that described my experience. I slept a couple hours each night but was compelled to keep moving. I worked on various projects for hours at a time, periodically bothered by the sight of small, insect-like dots scurrying across my visual field. I felt restless, productive, and somehow rather pressurized from the inside. I was also unsettled by dissociative spells in which I’d suddenly feel as though I were wearing my body, but it wasn’t really mine. Or, I’d walk by a mirror and be disturbed by my own face, which seemed unfamiliar.

When the strange symptoms ended, I plummeted back into depression.

I decreased my Emsam dose and my ketamine dose and had much more typical ketamine experiences, although I still found myself unbearably restless after infusions. The incident was strange, but since it didn’t happen again to the same degree, we carried on with treatment for a few more months.

Do I Have Bipolar Disorder?

I explained some of these experiences to a psychiatrist recently. I was being evaluated for ECT, although I’m not yet sure whether I want to do it.

The doctor interviewed me thoughtfully and asked a lot of questions about my symptoms. When we reached the end of the evaluation part of the appointment, he said that I might have been misdiagnosed with major depressive disorder, when really my depression is of the bipolar type.

It’s just a theory, but this would explain why antidepressants haven’t worked very well for me, or at least not for very long. The antidepressants actually seem to trigger these odd experiences.

A blue seven-day pill organizer filled with medication near a glass of water on a coaster

There have been other times when my mood suspiciously shifted, like the first time I took Wellbutrin. A day or two after starting it, I felt dramatically better. I was motivated, energetic, and utterly thrilled with how well it was working. Of course, then I developed a rash and had to stop taking it, at which point, I spiraled in the other direction.

The second time I tried Wellbutrin (the brand-name instead of generic), I wrote a post titled “Depression on Fast-Forward.” Wellbutrin didn’t make me happier that time, but it did make me anxious, jittery, and restless. I wrote about feeling “an almost constant low level of adrenaline” and feeling mismatched, like I wanted to sleep but was unable to. Was this just a side effect, or something more? Was taking lithium what made the second trial less happiness-inducing than the first?

The Antidepressant/Bipolar Controversy

These and the other incidents I can identify always happen in response to something, usually a medication change. The question of whether antidepressant-associated hypomania (AAH), also called treatment-emergent affective switch, or TEAS, indicates an underlying bipolar disorder is a controversial one.

Some people think that you can have unipolar depression and be reversibly pushed into hypomania by antidepressants, while others believe that switch indicates the existence of an underlying bipolar disorder or a shift from unipolar to bipolar illness. It has also been suggested that AAH should form the basis of a new diagnostic label, “bipolar III.”

I have experienced multiple incidents in the last few years that felt like a dramatic change, complete with insomnia, high productivity, perceptual disturbances, and euphoria or irritability. And yet, I find it difficult to verbally describe these events in a way that emphasizes the aspects I think are important. I habitually understate the severity of my symptoms, which doesn’t serve me when I really need help but can’t communicate accurately.

I’ve sought a few opinions from professionals on this matter, and I’m having trouble just reaching a consensus on whether my experiences count as AAH or were simply improvements in my depression with some side effects sprinkled in.

Even when I make a concerted effort to be more emphatic, the theory sometimes gets dismissed because the episodes I describe are too short by DSM standards to be mania, and I didn’t have racing thoughts, go out and spend all my money, take unreasonable risks, or have grandiose plans. These are all excellent points, so I’m really not sure what to think.

The DSM has strict criteria defining bipolar I and II, but that’s not the only way people conceptualize the condition. Some experts believe bipolarity exists on a spectrum, and that viewing antidepressant-associated hypomania as part of unipolar depression contributes to an overdiagnosis of MDD and an underdiagnosis of bipolar II.

On the other hand, some authors argue that bipolar disorder is overdiagnosed due to inflation of the diagnostic criteria, making the concept of bipolar disorder too vague.

Stopping My Antidepressant

Given the number of conflicting theories out there, it seems unlikely that I’ll get a solid answer about my own experiences at this point. One way to clarify the picture is to gradually get off my antidepressant and see what happens.

EMSAM-patch-packaging-with-label

I thought for sure I’d go back to the excessive sleeping I was doing before I started taking it, but so far, that hasn’t happened. I’ve been off Emsam for a couple of days, and the insomnia continues to plague me.

It’s troubling to look back at the last few years and imagine that there may have been a process occurring outside of my awareness. At the same time, I’m ever so slightly encouraged to have a different direction to go in. It could offer an explanation for some mysterious things and provide me with more effective treatments. Then again, maybe I have major depressive disorder, and I’m looking into a problem that doesn’t exist for me. Regardless of how it turns out diagnostically, I’m relieved to be connecting some dots.

5 thoughts on “Was I Misdiagnosed? Unipolar vs. Bipolar Depression

  1. “…and the insomnia continues to plague me.”

    Hi. I take Seroquel to help me sleep… it turns off the ‘voices’ / noises in my head long enough for me to fall asleep. When it’s not working, I’ll take a Zoplicone… it’s a straight up sleeping aid that’s not meant to be taken nightly. Are you taking anything specifically so you can get some sleep?

    I have a couple of slightly off-topic questions, I hope that’s cool… were the costs of the ketamine treatments covered by your insurance? Have the suicidal ideations gone away with the treatments? How difficult was it to find a therapist with experience in using ketamine?

    …Stella seems like a Good Dog.

    Like

    • Hi – thanks for your questions!
      I increased my seroquel dose a little, and it seems to be helping a little – at least for keeping me asleep. Turns out, the napping did start up again, so I’m making up for my poor nighttime sleep with some unhealthy escapist naps.

      The ketamine infusions were not covered by insurance, unfortunately. I know some people have had success appealing their claim rejections, but I think that’s rare. Spravato, the ketamine nasal spray, however, is more often covered by insurance.
      Ketamine helped me with my suicidal ideation for a while, but the effect started to wear off more quickly over time. So, while it would get rid of them for over a month in the beginning (during which time I could work on implementing skills and habits aimed at improving things longer term), they started to come back if I went too long between infusions. Eventually, whether because my depression worsened or the ketamine wasn’t working as well, I would only get about a week of relief from the suicidal ideation after an infusion. I decided to take a break from ketamine (or maybe stop forever – I’m undecided) a few months ago. Some people can go a lot longer between infusions and don’t seem to have any problem with them losing efficacy, though. It’s all so individual!

      I’m not sure if your last question is about ketamine assisted therapy or the infusions themselves, so forgive me if I’ve misinterpreted. The person who administered my ketamine infusions is an anesthesiologist who has a clinic specifically for using ketamine to treat mental health conditions. Only medical professionals can prescribe ketamine, so you might also see psychiatrists who offer ketamine options. If you were asking about the times when I did talk therapy during ketamine infusions, I actually just happen to have a therapist who was willing to try ketamine assisted therapy with me – she didn’t have any experience with it beforehand. My doctor (the anesthesiologist) was always present to monitor me medically while I talked to my therapist. I think some clinics have therapists on staff or whom they have worked with before to do therapy with patients, but mine didn’t.
      I hope that answered your questions! Stella is a Good Dog, for sure. 🙂

      Liked by 1 person

      • Hi… thanks so much for taking the time to answer! I’m fascinated by Ketamine as a treatment for depression. It’s not covered by insurance up here either, it’s mostly legal but the provincial Governments are still “studying” the benefits. From anecdotal evidence, however, it really seems like a miracle drug. At least for a little while. I have a few — five or six — Bloggers in my Feed that are using, or have used Ketamine as a treatment for Major Depression, and each one seems to have slightly different experiences regarding the longevity of the treatments.

        This article from CBC might interest you, and maybe answer some of the questions you have about how it works:

        “Ketamine works on the brain’s glutamate neurotransmitter, which is involved in communicating between nerve cells. The researchers think this is what provides the immediate effects of relief, which then becomes reinforced with the formation of new synapses.”

        Liked by 1 person

      • Hi! Sorry – I’ve never had anyone include a link, and it seems like WordPress did not like it. It wouldn’t let me approve the comment until I removed it. But it’s a really interesting article! Neuroplasticity is a very cool area of research all around. Thanks for sending it!

        Liked by 1 person

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