“If someone had used my medical school notes to try and diagnose me, they would have gotten it wrong.”
In her medical school classes, Jasmine says, “the one description of a manic person is someone dressed flamboyantly. Somebody screaming and coming into the ER wearing a tiara and a pink dress and talking fast.“ She laughs, shakes her head. “I’m sure somebody has presented that way.”
In my own clinical training, we learned very little about bipolar disorder. For bipolar 2 in particular, we learned that the depressive phases are severe, and the manic episodes are milder. As someone obsessed with efficiency and productivity, mild mania didn’t sound so bad at the time. So they talk quickly, think quickly, and don't want to take their meds? I thought. Seems reasonable. I sort of get it.
As it turns out, I did not "sort of get it." The things Jasmine and I learned in school represent only a small fraction of what it means to have bipolar disorder - and next to nothing about how it feels.
"I think it’s really valuable to get actual people’s experiences," she says. "It’s really lacking in our curriculums."
Here’s Jasmine’s story.
Fear and Stigma
“I can’t remember a time when I didn’t have some sort of mental health thing,” Jasmine says. “It’s just kind of part of me.”
Fortunately, her earliest diagnoses were readily met with diagnosis and treatment. At five, Jasmine’s kindergarten teacher noted that she was inordinately afraid of masked creatures. With the help of a therapist and exposure therapy at Chuck E. Cheese, that fear abated.
Slightly harder to manage was Jasmine’s phobia of spiders. The child therapist wasn’t helpful. Fifteen years later, neither are her med school classes. In fact, when they were learning about arachnobia, the instructor included images of spiders right on the powerpoint - as if he could safely assume that all 100 of Jasmine’s classmates were immune. Jasmine laughs again, and I’m beginning to suspect that her laugh means something else. “You realize people actually have this, right?”
“I always felt ‘othered’ for various reasons,” says Jasmine. “I’m queer. I’m not white.” Her parents immigrated from India, and she was one of only three South Asian students in her graduating class. “Boys would say dumb things, but a lot of the dumb things they would say were racist things.”
“I never felt desirable - I was the friend, the one who would help people with their homework, but would never get asked to a dance.” The last thing Jasmine wanted was to add a stigmatized label like “mental illness” to the mix. “I [didn’t] want to add something else that [would] make me seem different.”
In reality, Jasmine was so anxious for many years that, at times, she could scarcely eat, and was terrified in crowds. Until she was sixteen, she tolerated these symptoms in silence. “My coping skills tended to be, 'I’ll just distract myself and work on other things.'” For a time, this strategy worked quite well. In fact, she says, “the worse I feel, often the better I perform school-wise."
When Jasmine’s anxiety transformed into depression, her parents began to see the cracks in her armor. She dreaded going to school (although, of course, she always did). Her parents were alarmed. “Do we have to take you to the hospital?” “What’s happening to you?” Jasmine has a particularly painful memory of her mother asking, “What happened to my steady, stable daughter?”
There was deep shame in that. “I couldn’t be the one to be relied on anymore.”
Sex and college
Like many graduating seniors, Jasmine was prepared for college to fix everything. “In high school, I felt boxed into a certain identity. I was the smart one. I never got to be anything other than smart, and I really wanted to be other things.” She flew halfway across the country in pursuit of a "fresh start."
Jasmine had picked a school in Chicago in part because of the large South Asian community there. She soon realized, however, that their shared ethnicity did not result in a sense of kinship. They were all “very into being Indian,” she says. “All of their friends were Indian.” While she was raised with many Indian traditions, and was the first to educate her parents on many things “American,” Jasmine’s parents were politically and socially progressive. “Sneaking around and having to only date Indian people was not something I could relate to.”
Jasmine existed in an anxiety-inducing state of social “limbo” throughout her freshman year. As a sophomore, she finally found community in a group of fellow resident assistants. Through these friends, Jasmine was able to see herself with fresh eyes, to crawl out of the box that had defined her in high school. “I was still the smart one,” she admits, “but they also got to know my sense of humor more… I was fun, not afraid to dance with strangers."
Drinking and partying emboldened Jasmine to begin addressing her sexual inexperience. Indeed, she entered college having never been kissed. “Making out with guys made me feel cool," and helped to chip away at the self-perception she had constructed in high school. "I felt more desirable.” Still, not wanting to have sex was a point of disconnect between Jasmine and her peers; while she was not attached to virginity for religious or moral reasons, she couldn't bring herself to view it as something that needed to be erased. While her friends rushed to "get sex over with," Jasmine felt "other" again for sticking to what she was comfortable with.
Reflecting back, Jasmine says, "I wish I didn’t feel like I needed to do that to be an adult.”
During the Spring Break of her sophomore year, Jasmine had what she would later understand as her first hypomanic episode. “I just had lots of energy,” she says. At the time, she attributed it to being on break. “I remember feeling very creative. [Hypomania] is like an inner motor that’s just going and going.” The problem was that the episode didn't last - and the come-down was soul-crushing. A friend who saw her during and after told her, “You seem like you powered off.”
This, I reflected, is relatively consistent with media portrayals of bipolar. Bouts of creativity followed by periods of feeling down. Powering on and powering off. Not so bad, right?
It was a few months before Jasmine experienced more severe hypomania. She was traveling abroad, and the sleep disturbance triggered a manic episode. She couldn’t sleep and, perhaps more alarmingly, she couldn’t stop talking. “Like, physically, I couldn’t stop.” On the phone, her mom would later tell her that she could barely understand her. “My brain started going a million different directions in multiple languages. I would write all the way through 2-3 hour classes.” And this was not in some boy-genius Good Will Hunting kind of way, either. “I have felt clarity and understanding before,” says Jasmine. “This is not that.” “I felt like I was on a treadmill and couldn’t stop.”
“My brain started going a million different directions in multiple languages...I felt like I was on a treadmill and couldn’t stop.”
At a tour of one of the country's attractions, Jasmine reached a tipping point. The tour guide casually mentioned that lots of people had used this attraction to jump to their death. This planted a seed in Jasmine’s mind, a seed that she knew would quickly transform into action if she didn’t escape. “I felt like my body was being taken over by something,” she says. She didn’t want to kill herself, but it also didn’t feel like she was in control. “I didn’t want to jump, but I was afraid my body would do it."
One of Jasmine's friends observed the episode in full. As an interviewer, I am surprised to see that this is the real source of discomfort for Jasmine. “[My friend] had to take care of me," she says. “I had felt all these ways and she was witness to it.” As I listen to Jasmine, I hear the dissonance caused by falling apart in front of someone else, becoming a burden that others are forced to bear.
When Jasmine returned to the United States, her psychiatrist pulled out the DSM-5 and pointed straight to the criteria for hypomania. It described Jasmine’s experience to a tee. To Jasmine’s disappointment, however, she was given neither a diagnosis nor appropriate treatment. “We’ll watch it,” the psychiatrist said, and prescribed her an anti-anxiety medication instead.
What followed was the deepest depression Jasmine had ever experienced. A life-long musician, Jasmine abruptly stopped listening to music. She began feeling emotionally estranged from others. “I’d walk around campus and think, 'I feel horrible. I feel so alone.'" Eating was hard. Sleeping was hard. Waking up was hard. “I never miss class, and I missed class.”
Slowly, the suicidal thoughts began to encroach. “A trigger for me is seeing other people happy." When the Cubs won the world series, it felt as if all of Chicago was celebrating. They’re so happy and I’m not. I don’t deserve to be alive. Initially, the thoughts were passive: I hope I just don’t wake up. Soon enough, they were more active, and Jasmine began devising a plan to kill herself.
Luckily, around that same time, a few family friends were planning to visit. Jasmine was still herself enough to know that she didn't want to create problems for others. They'll be really sad if I die.
Searching for Diagnosis
While the manic episodes would start and stop abruptly, depression seemed to creep in and, just as slowly, creep away. But the fear of these episodes returning was more alive than ever. After graduating, Jasmine tried again to seek help from a psychiatrist. “Have you ever thought that you might have bipolar?” he asked her. “I’ve wondered," she said. But because Jasmine was unsure if her manic phase lad lasted four or more days, she was again denied the diagnosis.
“It makes me kind of upset that it took this long [to be diagnosed],” says Jasmine. “The feeling I got was that I needed to have something more severe happen to prove that this was bipolar.” And yet, especially in the case of bipolar, intervening early is important. “It’s common knowledge that not treating this stuff can cause [the episodes] to get worse.”
"The feeling I got was that I needed to have something more severe happen to prove that this was bipolar."
It was Jasmine’s family doctor who finally, and decisively, intervened. “That sounds like bipolar,” he said. “You need to start a mood stabilizer.”
“It was so validating to get the diagnosis,” says Jasmine. “After I started taking lithium, my life truly changed. I didn’t realize my mind could be so clear of unwanted thoughts.”
Maintenance and Meaning
For Jasmine, her bipolar disorder is now receiving precisely the right treatment. And yet, it is not cured. On a daily basis, Jasmine keeps a watchful eye for symptoms of hypomania. “Am I happy, or am I too happy? If I don’t get enough sleep, how come I’m not tired? I have to interrogate it.”
Jasmine is also watchful for signs of depression. Her most recent episode was typified by unwarranted feelings of guilt. It was in the early summer of this year, when COVID rates were on the rise and black lives matter protests were a daily occurrence in downtown Seattle. "I feel guilty for going to a protest during COVID times,” says Jasmine, but she also feels guilty for not going to a protest. “I was taking everything really personally...I was making this pandemic and racial justice thing about me.” In reality, this guilt had nothing to do with whether she went to a protest; guilt is a classic symptom of depression.
"I was making this pandemic and racial justice thing about me.”
Jasmine has monitored her mood and daily activity in a journal for over two years. Taking her medication, sleeping for eight hours, monitoring alcohol, and exercising are all integral to keeping her well. She goes to therapy and group therapy, and she has built a relationship with a partner with whom she can be fully transparent and vulnerable about her illness.
Perhaps most importantly, Jasmine has made meaning of her own mental health journey. By not drowning out her own feelings and experiences, she can create space for patients to share theirs. She also has the knowledge to ensure that she doesn’t repeat the mistakes of her past care providers, who could not or would not name her diagnosis.
“The truth is you can live a long life and prevent [negative outcomes] if you intervene early enough. [Bipolar 2] is one of the more treatable ones, and people don’t know.” As a future doctor, Jasmine is empowered by the gift of experience: she knows.