bipolar is man crazy, borderline is woman crazy
an essay on sex differences in which i try decompensation on for size
i recently decided that i am going to start going mask off.
at least sometimes. i resolve to start putting my art up in the streets again. i resolve to start dressing, looking, and acting insane in public again. i resolve to let myself be confused for a mad busker on the street.
this is in part because i’ve been doing research for an upcoming article about emilie autumn. something i noticed (among much else) is that when she was at her best, she was at her craziest. i am not at my authentic craziest, i think i’m pretty in control of my affects and behaviors, but the crazy thread still runs through me and is quietly the engine powering every interesting thought i have. if i am not honest about that, what the hell am i doing here? i resolve to present as disorganized, sneaky, esoteric, disarming, and out-of-my-mind as i experience myself. otherwise, who or what is this shit even for? what legitimacy do i have to gain by being super serious and doing capital letters all the time?1 who’s gonna tell me i’m a good girl for acting normal? nobody, or at least nobody whose opinion i give a damn about. if i’m gonna be an itinerant artist, a busking scholar, some brand of bohemian used book librarian, i better lean in. no one who has to carve their own niche in this way has the kind of psychological makeup that would allow them to do literally anything else. it’s time to get real.
alongside/in consort with my emilie autumn research, i’ve been noticing and thinking about sex differences in crazy person nosology.
basically, i’ve been thinking about how when men think and write about their own experience with being crazy they are likely to medicalize their experience (“I have a disease in my body for which i need to be medicated”)… whereas women are more likely to attribute their issues to What Happened To Them. that difference of attribution could be located in sexed dispositions (men be thinking and women be emoting), but i am increasingly inclined to locate the difference…elsewhere.
before i go there, i want to say i am not so much talking about Normal Person Mental Illness here. anyone can get ““diagnosed”” with general anxiety disorder and say “yeah that shit’s in my brain, i have a chemical imbalance :( ”, and where i live, people do that in spades. anxiety and depression are not sexed, they are literally a universal animal experiences, and even doctors know that on some level, which is why they’ll give lexapro to anyone who asks nicely. they don’t need to do a psych eval to know you’re suffering the human condition, and they don’t want you to suffer too too much.
no, i’m talking about the shit people can’t handle, the shit that will make people hate you.
you start posting online in a very insane way, let’s say. you tweet all through the day and night. you tweet about politics, about internet miscellanea, about hurting people and hurting yourself. you tweet slurs. you get in fights with other twitter users in a way that doesn’t really make sense. you can’t help it; you have to fight. you are itching out of your skin. you’ve got so much detritus pent up inside you and you are trying you level best to keep it off of your loved ones, so you spray strangers on the internet. you’ve got ghosts screaming at your from every direction, and that’s why you’re on the internet in the first place—you’re drowning them out. and the pain, the pain. the chest pain, the head pain, the stomach pain. you need for it to stop. you can’t make it stop. you rattle around inside you little office alone, inside your own head and your own body. one night after a particularly strenuous 3 am tweet storm, you leave your house. you are not quite in your body, so you don’t know where it’s taking you. you are sweating even thought it’s just above freezing and you’re not wearing socks under your shoes nor a coat. it’s fuzzy grey just before sunrise when a policeman approaches you. you are sitting on a bridge above the dammed river, right above an open sluice, which is gushing. you don’t remember coming here. there’s a loud buzzing in your ear that overpowers the roar of the water beneath. the policeman says something to you. you know you have to act civil or the cops will do something to you, so you do. you calmly answer the cop’s questions, you answer honestly. as you do, you realize you are cold, you start shivering. you are aware that the cop is telling you something about your wife. your wife is worried about you. a memory flickers through your head. a fight. yesterday? you yelled, you think, screamed. you cringe, you twinge bodily with regret. the cop mentions twitter. he’s seen what you posted. he’s worried, people are worried, worried as they are angry. the cop is inviting you into his car. you get in. you arrive at a gleaming white hospital. the nurse techs give you a blanket, snap a bracelet on your wrist.
now, choose your own adventure: are you a man or a woman?
if a man: they admit you for a 72 hour hold. some big group of people take you into a small room with a mirrored window. one of the men asks you what meds you’re on, have you been taking them? seroquel, lamictal, yes. why were you at the river? you don’t know. were you thinking about hurting yourself? no, you don’t think so. do you feel like hurting yourself now? no, you don’t think so. are you seeing things other people aren’t seeing, hearing things other people aren’t hearing? no, you don’t think so, but how would you know? the man laughs. have you ever had times where you had too much energy or felt invincible? sure. is that happening right now? no. the man asking the questions seems satisfied, the group leaves. a while later the man comes back, this time by himself. he says that it seems like the seroquel lamictal cocktail isn’t cutting it and it’s time to stop those and try lithium. you were hoping it wouldn’t come to this, but you knew they’d eventually try it on your bipolar ass. you leave the tiny room. you remain in the hospital for 72 hours, plus an extra 48, to make sure the transition to your new drug goes smoothly. your wife comes to visit. you are embarrassed, you are scared, you are so, so tired. your wife is kind and loving, though she seems tired, too. the transition to your new drugs goes as well as it can. you just want to go home, you are exhausted and wrung out. you hate psych hospitals, they always wear you out. you wish they would stop sending you here. the hospital releases you right on time with your new drug regimen.
if a woman: they admit you for a 72 hour hold. some big group of people take you into a small room with a mirrored window. one of the men asks you what meds you’re on, have you been taking them? fluoxetine, lamictal, yes. why were you at the river? you don’t know. were you thinking about hurting yourself? no, you don’t think so. do you feel like hurting yourself now? no, you don’t think so. are you seeing things other people aren’t seeing, hearing things other people aren’t hearing? no, you don’t think so, but how would you know? the man smiles curtly. have you ever been hospitalized before? yes. how many times? three. over how long a period was that? a few years, you don’t remember. can’t they look in their records? you ask. the man smiles curtly once again. he seems satisfied, the group leaves. a while later the man comes back, this time by himself. he says that it seems like the fluoxetine lamictal cocktail isn’t cutting it and it’s time to stop those and try latuda. latuda, what’s that? you’ve never heard of it. it’s an atypical antipsychotic, and off label, it’s one of the only drugs thought to work well for the mood disturbances of borderline personality disorder. borderline personality disorder? you don’t have borderline personality disorder, no one who has ever treated you has said you have it. well, the diagnosis is in your file, and the diagnosis stays, says the man. i don’t have BPD, ask anyone who’s ever known my case, you want to scream at him. you don’t, because you know that would be hallmark borderline behavior, and what would be the point of that? you leave the tiny room. you remain in the hospital for 72 hours, but the new drug gives you tremors and heart palpitations, which the hospital staff take for panic attacks, so they hold you in the hospital for an additional week. your wife comes to visit. you are embarrassed, you are scared, you are shaky, you are so, so tired. your wife is kind and loving, though she seems tired, too. you just want to go home, you are exhausted and wrung out and your body feels alien. you hate psych hospitals, they always frighten you. you wish they would stop sending you here. they keep tacking on extra days to your stay because you seem so freaked out. they finally let you go with a referral to a DBT-based partial hospitalization program.
so check it out. with identical presentations (excepting medications—note that the man is already on bipolar medication), a man gets treated for bipolar (a highly psychiatric, medicalized diagnosis—it’s In Your Brain and probably genetic, they say), while a woman gets “diagnosed” with BPD (a squishy, metaphysical, intersubjective, historically psychoanalytic diagnosis that is often attributed to What Happened To You, and is also colloquially synonymous with “evil”). bipolar is the crazy man disease, BPD is the crazy woman disease, and the doctor tells you so, if not in so many words. a man gets sent home with new drugs, drugs with a lot of empirical weight behind them. a woman gets sent home with a new drug with very little empirical weight behind it, plus the admonishment to go work through her shit in intensive therapy, the one devised for hysterics.
men, in my experience, are so eager to see their issues (from GAD2 to bipolar I) as brain-based and therefore not their fault, and doctors are all too happy to confirm this for them. women, if their problems are anything worse than run-of-the-mill depressionandanxiety, don’t even have that option; we get providers who tell us that whatever is wrong with us is definitely and deeply our responsibility to solve through our own grit and emotional capacities—oh and MONEY. no one is asking the freddie deboers of the world to just go to DBT, yknow? if you’re a man in this day and age, working on your shit means getting on wellbutrin. if you’re a woman, working on your shit means getting on wellbutrin AND spending thousands out of pocket on 1) dog training your dumb stupid animal brain or 2) doing special dance moves or 3) combing through your trauma ad infinitum.
i don’t know what of this, exactly. people much smarter than me have been writing about the gendered nature of psych diagnosis for much longer than i’ve been alive. it’s just a thing that’s been on my mind in a big way because most of my social circle is men, plus i have been annoying myself with freddie deboer recently. no one has it good out here if they’re trying to stop being in profound pain, of course. but crazy men get to just be like “i have a literal disease entity in my body and that is why i behave this way” and people will nod along. women absolutely do not get to do this. i man you can try, but, à la emilie autumn, you won’t succeed in getting people to nod along with you. i don’t believe that it’s literally true that psychic pain originates in individual heads, be they chemically imbalanced (whatever that means) or not, which is part of why it upsets me so much when men talk and act like it IS completely literally true.
at the end of the day, both the man imperative (take your drugs to fix your broken brain) and the woman imperative (get psychospiritual intervention to fix your broken soul) are both completely neglecting something pretty important: the rest of the world that is not YOU. sorry i know it’s hard to hear sometimes but circumstances, environmental factors, spiritual factors, ancestral factors, socioeconomic factors and OTHER PEOPLE do in fact affect you. in 100% of cases, whatever is wrong with you is influenced by these. don’t forget it.
especially (forgive me) if you are a man
i am still gonna finish my more “““scholarly””” essays tho, fear not. i am very out of my depth with the psychiatric portion of my research, so it’s taking a long time because i am self conscious and have so much more background reading to brush up on
yes i am mentioning GAD a lot in this essay, it is because i am coming out publicly as a GAD hater
Oh and read Charles Nemeroff's work, he's a very naughty boy but a good scientist non-the-less and he's done a lot with cortisol since Bernard Carroll died, even though Bernard road him for years over the pharmaceutical payouts. Oh oh and Ian Brockington has some lectures up on YouTube talking about cycloid and bipolar in women. Oh and watch Nassir's lectures, he's too influenced by Akiskal and Kouk but he's got some good ideas.
You seem to be aware of the historical background of borderline, and your description of the psychopharmacological approaches is freakishly accurate.
I assume you've read Hannah Decker's book and know how borderline ended up in the DSM?
I assume you've read all of Edward Shorter's books?
I assume you're familiar with Hagop Akiskal's agony over borderline — his idea of “lamotrigine deficiency syndrome,” and how the diagnosis vexed him throughout his career?
I’m guessing you already know all of that.
But have you read Ian Brockington and Carlos Perris’s work on cycloid psychosis?
What about David Healy’s research on the women admitted to the Denbigh asylum in North Wales?
If you're anything like me, you probably followed the Kraepelin–Jules Angst–Robert Post–Akiskal–Koukopoulos–Baldessarini lineage — the Boston–Rome pathway. But there's another route, often overlooked: Angst’s research partner Carlos Perris followed a different trajectory, diving into WKL nosology. That path leads through Wernicke, Kleist, Leonhard, Fish, Perris, Brockington, and Bernard Carroll. The secret to the second path is that Perris and Brockington focused on peripartum and perimenstrual cases, and Carroll took this and focused on the endocrine system. The idea they had was that by examining de novo episodes of bipolar in the postpartum period, it might reveal a distinct phenotype, with discrete etiology and pathogenesis — or rather, you would at least know the etiology involves postpartum effects, thus ruling out a big chunk of other possibilities.
Both lineages have borne fruit in terms of treatment, and together they hint at something deeper: bipolar might actually consist of two distinct diseases — but not Bipolar I and II as we currently define them.
By now you've probably read about how David Dunner rushed the bipolar I/II split, and how he later regretted it. The real split might be between periodic illness and cycloid illness.
And this is where Bernard Carroll may have come close to solving the other half of the puzzle that Koukopoulos and Akiskal were chasing. For years, Akiskal, Koukopoulos, and Baldessarini were noticing a subset of patients who “switch” very suddenly, with more “mixity.” Carroll, meanwhile, was researching premenstrual tension — and I don’t mean “PMS” or “PMDD.” I mean tension — inner agitation, explosive rage, irritability — a distinct syndrome that separates out from PMS and PMDD.
Here’s the strange part: Carroll’s phenotype bears an uncanny resemblance to akathisia and the more extreme, volatile presentations of borderline. Think of the old “larval epilepsy” cases — what Falret and even Kraepelin thought might be post-ictal states. The big kicker though is that it also resembles these mixed switching types that Akiskal, Kouk and Ross were so interested in, the "irritable" ones.
Picking up on that thread, a few years ago Gabriel Sani tried treating PMDD with acetazolamide — with incredible results. I asked Alexia about it, and she said the idea was based on its anticonvulsant action, i.e., Robert Post's ideas. But here’s where the whole story comes together — where the two research paths finally intersect. The second type of bipolar — the female-predominant, irritable-mixed-switchy subtype — may have something to do with intracellular fluid retention.
I assume you know how to use Sci-hub? Check these out, keep an eye/ear out for this idea of "irritablity" and "inner tension".
https://rxisk.org/antidotes-for-akathisia-and-dysregulation/
https://www.mcleanhospital.org/video/lecture-mixed-features-mood-disorders-historical-and-current-clinical-implications
https://www.youtube.com/watch?v=VHpWh0fsyVI
https://www.mcleanhospital.org/video/lecture-mixed-features-mood-disorders-historical-and-current-clinical-implications
https://www.youtube.com/watch?v=VHpWh0fsyVI
https://pubmed.ncbi.nlm.nih.gov/24605130/#
https://pubmed.ncbi.nlm.nih.gov/7193399/
Oh and read this book: https://www.amazon.com.au/Mania-Short-History-Bipolar-Disorder/dp/1421403978
Its the best book I've ever read on the history of mental illness. David outlines some of his hypothesis but only in a vague way, so if you don't know, you could miss it. He's a very scientific thinker so he presents it very tentatively and even when pressed he is extremely frugal in what he is willing to speculate. But if I had to "bet the ranch" on who is going to solve Aksiskal's "BPD mystery", I think David is damn close to cracking it and I'd be keeping an eye on his blog.