You know what still gets me, even after twenty-two years doing this? You just can't beat the look on someone's face when it all finally comes together. Last Tuesday, I watched Sarah settle back into the chair, slowly shake her head, and say, "So that's why I have felt like I am living two different lives."

David was my wake-up call three years ago. He slumped in the same chair with all the energy of a hyena, and said to me about his wife, "She never really knows which version of me she's going to get. Some days I am finding inspiration at midnight and organizing the garage and starting out on three new businesses, and other days I can't even bring myself to get out of bed and take a shower." When he said, "I really think something is seriously wrong with me doc," the satisfaction in his voice when we finally figured out he was experiencing symptomologies of the condition we call 'bipolar' is why I do this work.

Here's the thing nobody warns you about with bipolar disorder: it's a master of disguise. People walk into my office thinking they know what's happening—usually convinced it's just depression—and then we start peeling back layers they never even knew existed.

The Sneaky Truth About Bipolar

Most folks have no clue they're dealing with bipolar because the depression episodes are what drive them to get help. Makes sense, right? Who goes to therapy to complain about feeling amazing? Those hypomanic periods—the ones that have you reorganizing your entire life at 2 am, feeling like you're able to conquer the world—those are assumed to be filed away as "finally feeling like myself again."

I have lost count of how many times I have heard someone say, "Oh, that month when I painted my whole house and started learning Portuguese? I was just really motivated." In the back of my mind, I am thinking, "Dude, that is not motivation, that is hypomania."

The detective part of this job is my favorite part. It's not like strep throat. You don't just get a swab and then a test and then you are finished. This requires patience, paying attention to what people aren't saying, and honestly, trusting my gut after years of experience.

I typically start more simply, "Tell me about your mood patterns." But then we start to dig. If someone mentions that they went five days hardly sleeping but felt, "fantastic and productive," my antennas are up. If they mention they are making the best decisions that ended up causing problems later on, I am connecting dots they aren't even aware of; this is when I start livestock detective work.

Believing what someone shares with you is paramount. People are embarrassed by their mood swings and frightened of being seen as "crazy." Creating a safe environment where someone can honestly look at their patterns without fear is often the only difference between a right diagnosis and treatment or many, many years of hair pulling spinning wheels with every wrong sorts of treatment.

The hardest for cases to work with? Mixed episodes. Good luck untangling someone agitated, hopeless, and energized all at once. It is enough to wear people out and confusing everyone's mind. But when we do figure it out—that moment when I can see that are relieved that everything is sorted. The relief on somebodies face in that moment when it all clicks—that's everything.

David told me the other day, "For the first time in my adult life, I finally understand myself. My wife says I'm still me, just the stable version." That's what we're after: not changing who you are, but helping you understand and manage who you are.

Why Getting Answers Takes Forever (And Why That's Actually Normal)

Want to know something that'll blow your mind? Most people wait about a decade before anyone figures out what's really going on. A whole decade. That's longer than medical school, longer than most jobs, longer than some marriages.

It's not because doctors are idiots or the symptoms are impossible to spot. It happens because bipolar disorder is fundamentally sneaky.

Take Marcus. Eight years of being treated for depression. Multiple therapists, six different medications, several scary hospitalizations. Everyone kept focusing on the crashes—when he couldn't get out of bed, couldn't work, couldn't shower for weeks. Nobody asked about the other times. When Marcus felt "finally normal again." When he wanted to tackle massive home reno projects until 3 a.m. and had tons of energy. When he would sign up for three evening classes and actually go for at least a few weeks. When friends said that he seemed to be "really on" lately.

You see, hypomania doesn't really feel like a problem. It feels like being your best self. Who complains about feeling good?

What Bipolar Really Looks Like Day to Day

Forget what you have been in films: those intense emotional shifts every single hour? Totally fictional. The real thing is much more complex and, frankly, way more fascinating.

Real Mania: You Definitely Know It When You See It

Real mania doesn't look like someone who is having a great day. It looks like someone is becoming literally different—like overnight their entire person is switched out completely.

Jennifer put it best last spring: "I felt like I was driving a Ferrari downhill with no brakes. Everything seemed possible, everything was moving at light speed, and I couldn't hit the stop button if my life depended on it."

Her ten-day manic episode included:

• Two hours of sleep nightly, yet feeling like she'd had the most restful sleep ever
• Writing what she was absolutely convinced would revolutionize American literature (she'd never written anything longer than an email)
• Completely rearranging her home based on feng shui principles from a three-hour internet rabbit hole
• Dropping three grand on professional camera equipment for her "obvious" new photography career (she'd never taken anything beyond iPhone shots)
• Developing unshakeable confidence she'd master Mandarin in three months

Jennifer normally researches $50 purchases for weeks. She needs her full eight hours or she's useless. She's never considered herself creative or impulsive. Her husband knew something was seriously wrong when she started making concrete plans to relocate to Costa Rica for a yoga retreat business—Jennifer had never attempted a single downward dog and spoke zero Spanish.

That's mania: becoming unrecognizable from yourself for days or weeks, making decisions that are genuinely off the rails.

Hypomania: The Great Pretender

Hypomania manifests itself as you finally becoming who you have always wanted to be. When someone is in a hypomanic episode they often:

• Work swiftly and brilliantly enough to impress others and get promoted
• Engage in interesting projects or meet fascinating people
• Experience a natural sense of confidence when socializing when usually awkward
• Work better than usual when given less sleep and more energy
• Have wonderful ideas to change their life for the better and reasonable

The catch? These represent distinct shifts from someone's normal operating mode, even when they look positive.

I remember one client whose mother would call me, worried because her son seemed "too upbeat" during family dinners. This guy was naturally quiet, methodical—classic accountant personality. But during hypomanic phases, he'd transform into the family entertainer, cracking jokes, pitching elaborate vacation ideas, staying up until 2 AM reorganizing his garage or researching whatever had captured his attention that week. His family could see these differences from a mile away, while he felt like he was swooping into the zone.

The Depressive Crashes: When Everything Falls Apart

Bipolar depression is not a whole lot different from regular depression, but it feels even worse because of the preceding mood. It is like going from thinking you're a superhero to just being able to stand long enough to brush your teeth.

The whiplash is psychologically brutal. You get all the usual suspects: persistent sadness, losing interest in everything, sleep problems, appetite changes, exhaustion, guilt, concentration issues, sometimes thoughts of death or suicide. What makes them particularly cruel in bipolar is how they often follow periods of elevated mood, creating cycles that feel utterly hopeless.

How We Actually Figure This Out: The Real Process

Diagnosing bipolar isn't like getting blood work done. No, there is no diagnostic machine that beeps and produces results. Real diagnosis is detective work—gathering history, identifying patterns and connections, and along the way sometimes you wait to see how symptoms evolve.

The First Conversation: The Hidden Stories That Unravel Hidden Truths

All begins with conversation. Not coffee talk but intentional exploration to find the hidden patterns in the time we spent together. Over the years, I've trained myself to listen for things other than words—tone, emphasis, hesitations, those complete non-verbals in the gaps on what someone will not say.

So when a patient starts to describe their depression, I'm already attuned to clues I can count on to indicate other mood states. If someone blithely states that these low periods of time "come and go"? I immediately want to find out what those "go" episodes looked like.

From trial and error, I honed in on questions that consistently can shed light on rarely explored hypomanic episodes:

• "Over the years do family, friends, and/or coworkers ever say that you seem like a completely different person during certain stretches? Maybe unusually vibrant or chatty?"
• "Walk me through the time when you amazed yourself at how much you got done. You accomplished way more than seemed remotely possible?"
• "Can you ever remember stretches of time where you hardly slept but felt completely wired and wide-awake the next day?"
• "In hindsight, are there stretches of time when you think to yourself....what was I thinking?"

Reconstructing the Timeline: Memory as Pieces of a Puzzle

The core of accurate assessment is reconstructing an accurate and detailed timeline of mood episodes. This is trickier than it sounds because memory gets weird, especially around mood states that felt good.

I often use life events as anchors. Did the depression start before or after the job change? What was your mood like during wedding planning? How did you feel that summer you moved apartments?

Sometimes I'll ask people to talk to family or look through old photos, social media posts, journals. Amazing how often someone returns the next week saying, "My sister reminded me about this time when I..." followed by a clear hypomanic episode they'd completely forgotten.

The Family Tree: Reading Between Generational Lines

Bipolar runs in families, but most families don't have neat diagnostic labels for relatives' experiences. Instead of just asking about diagnoses, I dig into family stories. I want to hear about the aunt who was "always either really up or really down." The grandfather with "big ideas" that never worked out. The cousin who was incredibly charismatic but whose life was marked by dramatic ups and downs. The uncle who was "eccentric" with a pattern of businesses that failed spectacularly.

Family stories can be goldmines for understanding inherited mood patterns. I remember working with someone whose grandmother became a family legend for her April cleaning sprees. Every Spring, she would spontaneously begin massive home renovations. She would stay up all night painting and moving furniture around. She'd take on undertakings that would wear most of us out. Her family thought it was charming. This apparent creative burst of energy each Spring with the warmer weather. I can't tell you how many times I heard this type of story and my clinical antennas went off. What the family think is an endearing seasonal enthusiasm was hypomania and that was as plain as day to me.

The Value of Outside Perspective: When Everyone Else Sees What We Don't

I obtain some of the most important diagnostic information from people who know the person well. With permission, I may schedule a time to meet with family, friends or significant others and ask them questions directly such as:

• "How often has Sarah had times when she seemed revved up, or just... different somehow"?
• "Has his sleep ever gone completely crazy?"
• "Did she ever have times when she made decisions that surprised you because they were so unlike her"?

Gathering information from an outside observer is absolutely crucial when hunting for hypomanic episodes. Hypomania can be fantastic for the person experiencing it, but can be obvious to everyone around them, like a neon sign.

I will never forget one assessment when the guy was adamant he did not have any periods of hypomania. Not even once. Then his wife chimes in: "Every few months, he will have these intense fixations. The last fixation was guitar. He practiced until 2:00 a.m. He talked a mile a minute about chord progressions and starting a band! Prior to that, he totally redesigned our whole kitchen in one weekend; he drew diagrams for all the work. He gets mad at me when I suggest that he may want to take a beat."

To him, these were examples of a positive period of motivation to her they were clearly things outside of his normal personality.

Making Sense of the Categories

The official manual outlines specific criteria for different types of bipolar, but applying these in real life requires considerable clinical judgment.

Bipolar I: When Mania Makes Things Clear

Bipolar I requires just one clear manic episode in someone's lifetime. Here's something that catches people off guard: you don't actually need depression to get a Bipolar I diagnosis. The majority of people individually experience depressive episodes, but one of the technical criteria for BD is at least 1 real manic episode.

Sounds easy, doesn't it? Not really. Determining if a person ever truly experienced mania, is something akin to putting a puzzle together, but the box doesn't have a lid and half the pieces are missing.

I have heard what sounds like mania (racing thoughts, grandiosity, insomnia), only to find out whole episode was triggered by steroids. Or a medication (antidepressants). Maybe they were coming off alcohol or had undiagnosed thyroid issues running wild.

The real detective work happens separating authentic mania from everything else that can mimic it. These distinctions matter enormously because they completely change how we understand what's happening and what comes next.

Bipolar II: More Common but Harder to Spot

Bipolar II requires at least one hypomanic episode and one major depressive episode, with no full mania history. This is actually more common than Bipolar I, but often gets misdiagnosed because hypomanic episodes are subtle and feel good.

Many Bipolar II folks spend years being treated for depression alone, often with limited success. The depression keeps returning despite treatment, sometimes triggered by the very antidepressants meant to help.

Cyclothymic Disorder: The Roller Coaster Life

This involves numerous periods of hypomanic symptoms and depressive symptoms that don't quite meet full criteria, lasting at least two years.

"It's like living on a roller coaster that never stops," one client told me, perfectly describing her cyclothymic disorder. Not the dramatic highs and crushing lows that land people in hospitals, but relentless constant ups and downs that wear away at relationships, careers, any sense of stability.

When Nothing Fits the Textbook

Real life ignores diagnostic manuals. Some of my most puzzling cases involve people whose symptoms dance around every category's edges without settling anywhere.

Take the woman who cycles through mood episodes in days, not weeks. Or the man whose depression comes with bursts of frantic energy and zero sleep. The teacher whose mood predictably crashes every October and soars each spring, but never quite severe enough for clear seasonal patterns.

These complex cases demand patience and creativity. Sometimes I'll work with someone for months before the real pattern emerges from what initially looked like chaos.

When Everything Gets Complicated

Certain factors can turn straightforward assessment into a labyrinth, explaining why some diagnoses take forever to sort out.

The Substance Use Puzzle

Here's where things get really messy: drugs and alcohol can perfectly mimic bipolar symptoms while also making genuine bipolar worse. I've seen cocaine create "manic" episodes so convincing they fooled everyone. Conversely, alcohol may exacerbate depressive symptoms in people who already have difficulties due to mood disorder.

The million-dollar question: the chicken or the egg? In some situations, the only way to figure that out is through months of sobriety, which is problematic as people may use substances to escape what may be an unbearable untreated state of mood swings.

Medical Masqueraders

A number of medical conditions also produce mood symptoms which resemble the diagnostic criteria for bipolar disorder. Your thyroid can absolutely wreak havoc on mood. I've seen hyperthyroidism create textbook-looking mania—racing heart, racing thoughts, barely sleeping, grandiose plans—while underactive thyroid can drag someone into severe-seeming depression.

This is why I insist on thorough medical workups. I can't count how many times "treatment-resistant depression" turned out to be undiagnosed thyroid problems, or "anxiety and mood swings" stemmed from sleep apnea.

When Other Conditions Crash the Party

Borderline personality disorder loves to crash the bandwagon, same with the adhd, anxiety disorders, and ptsd. These conditions flirt with symptoms that lead to incorrect diagnosis.

The trick? The pattern of time. Bipolar disorders run sporadically with episodes that have distinct beginnings, middles, and ends with time periods of normal function in between. Personality disorders create more consistent chaos. But these conditions can absolutely coexist, creating presentations so complex they require completely individualized treatment strategies.

Beyond Initial Diagnosis: The Real Work Begins

Getting a bipolar diagnosis isn't the finish line—it's mile marker one in a lifelong marathon of understanding yourself and your condition.

The Art of Mood Tracking

Some of my most successful clients become detectives of their own patterns. They track everything from mood rating, sleep, energy, social engagement, and big stressors. Smartphone apps have changed this tracking in very observable and extensive ways, and patterns may now be seen that could not be seen before they could not be seen before.

A client had a manic episode every time she had certain combinations of stress and sleep deprivation. Another client had the same pattern of depression in certain weather patterns. This self-knowledge becomes incredibly powerful for prevention and early intervention.

That said, tracking isn't for everyone. Some find it empowering; others become obsessed or anxious about constant monitoring. The approach has to fit the person.

When Treatment Tells the Real Story

Sometimes the clearest diagnostic information comes from watching treatment response. Bipolar has distinct medication fingerprints. Give someone with bipolar depression an antidepressant alone, and you might trigger mania or rapid cycling. Add a mood stabilizer like lithium, and suddenly everything clicks into place.

I've had clients whose diagnosis became crystal clear only after seeing how dramatically they responded to bipolar-specific treatments.

The Human Reality: What It's Actually Like Going Through This

While I've outlined the clinical aspects, it's crucial acknowledging the emotional reality of seeking bipolar evaluation. This whole process hits hard—with an emotional freight train that can be overwhelming, disorienting, and downright draining.

Battling Fear and Hollywood Fantasy

Most people walk into my office with their heads full of dread about bipolar as many of us have worked to develop the devastating stereotypes associated with it, relying on sensationalized films and imagined tragedies, and they really think it means that they are "crazy," that they will not be in control of their own body and mind, or, worst of all, that their lives are basically over.

I spend considerable time untangling these fears from reality. I've worked with people who suffered for years rather than seek help because they were petrified of getting a bipolar diagnosis. These fears make complete sense considering what most people think they know about bipolar. But they're usually built on misinformation and Hollywood drama, not medical reality.

The truth? Most people with bipolar live full, productive, meaningful lives. They have careers, relationships, families. They travel, create, achieve goals. It's not the life-ending catastrophe most imagine.

The Emotional Whiplash of Finally Getting Answers

When someone finally receives accurate diagnosis, the emotional response is never simple. There's often profound relief—"Finally, someone understands what I've been going through!" But that relief comes tangled with grief over lost time, misdiagnoses, treatments that didn't work, relationships that suffered while they struggled without answers.

There's also the challenge of integrating this new self-understanding. Someone who thought they were just "moody" now has to reconceptualize their experiences as mental health condition symptoms. This can be both liberating and overwhelming.

What Happens After Assessment: Building Your Road Map

Getting through comprehensive bipolar assessment gives you the roadmap, but now you actually have to take the trip.

Developing Treatment Plans That Actually Work for You

After everything we've learned—your bipolar type, the way your episodes typically evolve, what seems to cause them, your home life, your goals—leads me to the next stage. Medication? Of course talking about it. Therapy? Almost certainly involved. Lifestyle adjustments? Sleep hygiene, stress management, fitness? All the options are on the table.

But here is the one thing I have learned: no treatment plan is worth a damn, regardless of how great, if it won't fit your actual life. I won't recommend three-daily medications if you travel constantly for work. We won't plan weekly therapy if you're a single parent working two jobs.

Planning has to be genuinely collaborative. You're the one living with this condition and following this treatment plan, so you get a real voice in how it looks.

Building Your Personal Emergency Plan

One of the smartest things we can do together is create a roadmap for when things go sideways. And they will—that's part of having bipolar disorder. The goal isn't to stop every event but to identify them as early as possible and manage them as smoothly as possible.

Your early warning signs are your own personal weather alert. You might stop text messaging back before depressive episodes, or you might start talking fast and sleeping little before you go into mania. However you learn to identify your unique identifiers, you can jump on them early—alter medications, increase therapy, ask support for help, clear your schedule.

The Real Story: What Life Actually Looks Like

Let me be completely clear: bipolar is serious, requires ongoing attention, and will probably always be part of your life. But it absolutely doesn't sentence you to diminished existence. I've worked with people with bipolar who are doctors, teachers, artists, parents, entrepreneurs, activists. They travel, create, build relationships, achieve goals.

Becoming Your Own Expert

Over time, you'll develop almost scientific understanding of your own patterns. You'll know job stress combined with poor sleep is your perfect storm for depression. You'll recognize spring weather changes tend to trigger mild hypomania. You'll learn relationship conflicts hit you harder than others, and plan accordingly.

This self-knowledge becomes your superpower.

Balancing Hope with Reality

Here's honest truth: bipolar isn't going anywhere. It's a lifelong condition requiring ongoing attention and management. But it doesn't have to define your life's limits.

I've worked with people with bipolar who are surgeons, writers, teachers, parents, business owners, artists. They travel the world, fall in love, raise kids, start companies, create beautiful things. Their lives do not become smaller or less meaningful because of their diagnosis.

The sweet spot is in realistic optimism. Yes, you will likely deal with this condition for your whole life. Yes, it is possible to have setbacks, to adjust treatments. However, it is very possible to manage it effectively, to manage your symptoms, to live a very full, rich life despite this condition—and sometimes because of it.

Where We End Up: The Journey Keeps Going

If you are worried about bipolar disorder in yourself, or in someone you care about and are reading this, I want to acknowledge that figuring out if you have a mental health concern is difficult, and seeking out an assessment takes tremendous courage. I don't want to minimize how anxiety-provoking the entire process is, but the model of assessment is intended to provide clarity where there has been chaos, provide understanding where there has been fear.

The assessment belongs to you. Your experience, observations, and concerns are important. Do not hesitate to ask questions, or share what is really going on. The more honest and full the picture, the more clarity we can all have about what is going on, and what needs to be addressed.

Here is what I want you to take away: no matter what we discover in the assessment, taking ownership of your mental health is worth it. Maybe the assessment leads to a diagnosis of bipolar disorder, and we build treatment around that. Or maybe it points to something else entirely. Maybe the assessment shows that everything is ok, and you walk away with clarity and a better understanding of yourself. All of these outcomes are valuable.

What you are seeking is not just a diagnosis - you are taking ownership of your mental health, and your future. Mental health is not a problem you fix once and forget about. It is more like physical health - something that you attend to consistently, with peaks and valleys, good days and not-so-good days. However, every step you take toward better understanding of yourself, every tool you learn, every support system you develop - these things make the whole journey easier.

The most important step is that first step of making the call, even when it often feels the hardest. Everything else - all the insights, treatment, stability, progress - flow from that one step. One conversation at a time, one day at a time, one small victory at a time. It will not always be easy, but there is a genuinely hopeful destination: a life where you understand yourself, you have what you need to provide care for yourself, and you can build something meaningful while navigating the challenges that life can bring.