29 1 / 2013

Bipolar Sherlock

Does Sherlock have a bipolar affective disorder? Is he a manic depressive?

  • some general myth busting about bipolar
  • I give a psychiatric evaluation of Sherlock’s mood
  • explain how to produce a realistic version of Sherlock with bipolar for any aspiring fanfiction writers.

 

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Myth Busting

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Bipolar affective disorder sometimes called “manic depression” is one of the most common mood disorders in the world (after depression). However, unlike straight depression, it takes longer to reach a definitive diagnosis and can be harder to treat.

Bipolar classically presents as periods of abnormally elevated mood and/or irritability followed by periods of depression.

The presentation of bipolar is very variable in pattern, form and severity. There is not a one size fits all description for every individual. Bipolar affective disorder is considered by some psychiatrists as an aggregation of distinctively different disorders rather than one single disease. 

The most common presentation is classic bipolar - mania/depression/remission cycle. 

The general public have a rather strange misconception that bipolar disorder causes people to very emotionally unstable – swinging between joy and sorrow many times a day. This is emphatically not true (unless you have ultra-rapid cycling bipolar which is a rare and incredibly severe form that requires hospitalisation. Not to be confused with rapid-cycling which occurs more frequently is not always a cause for concern).

In classic bipolar your manic/depressive episodes have to be persistent, consistent and last for more than 4 days each. If left untreated patients have episodes that can last weeks. Their mood is relatively stable throughout this period without any oscillation between high and low. The decent from mania into depression occurs over days not minutes and once you are depressed you stay depressed for significant period of time.

It is also possible to have bipolar without depression and only periods of mania and hypomania (mania that is less extreme). You can also have a double dip kind of bipolar whereby you become depressed and then even more depressed. Alternatively you can have mixed episodes. This does not mean you are happy one minute and sad the next. A mixed episode is where you exhibit symptoms of depression and mania but your mood is relatively stable - either elevated or depressed.

Bipolar is not an easy disease to diagnose. The disorder usually starts with a single manic/hypomanic episode that is not followed by depression. The first episode can be short lived and very subtle, even people who know the patient very well may not realise there is anything wrong, particularly if the episode coincides with something that would normally cause happiness anyway.

Then the patient goes into full remission for months to years. Typically there is a gap of about 2 years between the first manic episode and the second. The second episode is more commonly followed by depression and thus is more likely to prompt the patient to see a doctor.

The natural progression is for episodes to occur more frequently as time goes on and mood swings to become more intense, producing an ever more intense cycle of mania and depression with short periods of remission in between.

Bipolar can be treated but not cured. Lithium is the drug of choice and despite its side effects regulates mood very well for people with mild to moderate bipolar disorder.

Does Sherlock have Bipolar?

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In order to be diagnosed with classic bipolar you must have had at least one episode of mania/hypomania or one episode of depression accompanied by an episode of mania/hypomania. Diagnosing the unipolar (just mania or just depression) types of biopolar is more difficult. There is no set criteria and relies on the experience of the psychiatrist.

What is mania?

It’s more complicated than just feeling abnormally happy. In fact many people with mania may not feel happy at all, they might feel restless and irritable.

In order to have mania you must demonstrate persistently and consistently demonstrate at three of the following:

  • Elevate mood out of keeping with circumstances - Sherlock’s elevated moods are entirely in keeping with circumstances – we just don’t always realise until the end.
  •  Increased energy – Sherlock always has a limitless reserve of energy, his energy does not increase significantly during any particularly time. He merely has more motivation to do stuff when there is a case.
  • Increased self-esteem – Sherlock’s self-esteem appears to be constantly above the norm and does not increase.
  • Reduced attention/increased distractibility – During periods of elevated mood i.e. during cases, Sherlock appears much more focuses rather than distracted
  • Tendency to engage in reckless behaviour with serious consequences that would otherwise be avoided – Sherlock engages in risky behaviour to achieve specific goals. His risk taking does not increase over distinct periods of time for no good reason.
  • Other manifestations: aggression, irritability, suspiciousness, excitement.

The important point to remember is that during a manic/hypomania episode the patient must behave out of character.

If the patient is usually reckless, restless, aggressive and irritable, he must demonstrate that these characteristics become significantly more severe without any logical reason during a prolong period of time.  Seen as Sherlock’s elevated moods almost always coincide with either pursuing or solving a case, we can conclude that Sherlock has a very logical reason to be happy and his mood is not abnormally elevated.

In fact he behaves more like he is having a manic episode when he’s not on a case. However we know that this behaviour is due to boredom rather than neurological changes beyond his control. If Sherlock truly had bipolar, his episodes would not coincide perfectly with his work schedule.


As Kate221B has pointed out:

Rapid cycling bipolar type 2 is my diagnosis. I think that he’s learn to induce a hypomanic episode to help him on a case - I don’t think he’s ever been truly manic. I think that the features of hypomania - the ability to go without sleep for prolonged periods of time, to work at twice normal speed , to think incredibly fast all help him, and then he hits a low afterwards, which is exactly what ACD describes. Long periods of sitting or sleeping, hardly moving or talking, not leaving the flat etc, then back to normal until the next time.

The problem with rapid cycling type 2 is that it often displays violent swings between manic and depressive. I am just not clinically convinced that Sherlock is ever depressed. He is less energetic because he has less motivation to be energetic (more about this later) 

He certainly has some symptoms of hypomania but in order to have hypomania you need to have a remission state or a “norm” to compare the hypomania symptoms. 

I think it is unlikely that Sherlock has a purely manic or a purely depressive type of bipolar disorder.  The usual pattern contains periods of time where Sherlock should essentially be in remission – i.e. behaving normally. However we do not see periods (even short ones) during which Sherlock behaves significantly more calmly or more “normally”. In essence what we see of Sherlock is not one extremely long manic episode (they do not last for eighteen months at a stretch) but rather what we see is his norm. He is naturally brimming with energy, self-esteem and recklessness.

Of course there is much room for interpretation even if Sherlock was a real patient, psychiatrists may argue amongst themselves for hours over his behaviour. 


Also BBC Sherlock behaves differently from ACD Holmes - and given I don’t know enough about ACD Holmes to comment, I suppose he might have bipolar affective disorder. 

In terms of mood fluctuations Sherlock tend to oscillate between joy and irritability but he does not oscillate between joy and depression. In fact Sherlock in the BBC adaptation has never shown signs of being depressed. He doesn’t talk for days at a time but lack of communication does not equate to depression.

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Depression is not just characterized by abnormally low mood, it also requires ahendonia (not enjoying the things one usually enjoys) and low energy. Sherlock has never displayed the latter two symptoms even during periods where he has low mood e.g. TRF. In TRF Sherlock has every reason to be sad, he’s about to fake his own death and devastate his only friend. I would be worried if he was happy – because that would actually be a sign of mania. Sherlock is still able to enjoy solving cases during times when he is “down”, in fact cases are the perfect antidote to his low mood, which shows that he is not actually depressed - he is merely sulking. As anyone who has been depressed will know, it takes time and a great deal of effort to life yourself out of depression. It will not happen instantaneously due to one set one stimuli.

Of course Sherlock may have had bipolar in the past, and is now on medication which controls his symptoms but I discuss later why Sherlock would object to treatment if he had bipolar.

Hence I do not think anyone could diagnose the BBC version of Sherlock with classic bipolar disorder. He also does not fit the pattern of the unipolar variety because he does not demonstrate any remission periods.

However Sherlock might just be hypomanic when we see him during the episodes. His remission periods might just be incredibly dull. 

"John, I’m going out to buy milk", "John I’ve done the washing up", "John I’ve cleaned the cadavers out of the fridge, honestly what was I thinking?"


So Sherlock might have bipolar but in my professional opinion he doesn’t. 

If anyone has thoughts about ACD Holmes than please do comment or message me.

But If Sherlock had Bipolar:

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For anyone who wants to write about Sherlock with bipolar, here is a short guide to making him realistic.

Bipolar disorder has a genetic component. You are seven times more likely to have bipolar if you have a first degree relative who also suffers from this condition. Hence Sherlock’s parents or his brother may also have bipolar. If this is the case, Sherlock would understand the condition better than most lay people. He may also be able to diagnose himself straight away once his first episode hit.

First manic episodes tend to occur between the ages of 15-25 and as I’ve said before the symptoms can be very subtle. If Sherlock does not have relatives with the disorder, he might not be able to pick up on the signs or even recognise them as bipolar. Manic episodes can be rather enjoyable, for a period of time you feel on top of the world! There is no reason why a patient would think this happiness is due to an illness.  If Sherlock has surrounded himself with temporary acquaintances who do not know him well, no one will be around to notice or remark upon his altered behaviour. They would merely regard his manic episode as the norm.

Alternatively Sherlock may be sadly afflicted with a more severe form of mania during his first episode, which may have had serious repercussions. Imagine how reckless Sherlock normally is and then multiply that a hundred times.

 I personally think his first episode might have come as teenager and his second episode during his university years which culminated in Sherlock being kicked out of university due to this more serious manic episode.

By the time he is 36 or so, without treatment Sherlock’s symptoms would be more extreme. The disorder would also become an established cyclical pattern of manic/depression/remission whereby the remission periods become gradually shorter so Sherlock spends more time being either manic or depressed. 

Episodes typically last longer as time goes on – lengthening from weeks to months.

 Sherlock is generally not the most organised of people when he has nothing to motivate him. He needs a good reason to do everything, and this includes taking medication. Lithium is the mood stabiliser of choice for people with bipolar. Unfortunately it is a tablet that needs to be taken every day and because it’s prophylaxis you are basically taking it indefinitely to prevent something that might happen at some point. I don’t think Sherlock would have taken kindly to this treatment regime particularly as the common side effects of lithium are an overall dazed feeling and fine tremor in the hands.

Added to this, lithium requires monitoring. If Sherlock is on lithium he needs to have blood tests every few months in order to adjust the dosage of his medication – if this is not done, he risks lithium toxicity which is potentially fatal. On balance, I think Sherlock probably threw his prescription in the bin.

Without treatment Sherlock would regularly cycle through mania/depression. If his first episode occurred as a teenager by the time we see him in the series, his disorder would have established a pattern of mania/depression.

Manic Sherlock

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Mania would not make Sherlock happier in a cheesy sort of way. He would not go skipping down the road, kissing babies and showering the world with love. Sherlock would be more aggressive, irritable, excitable and distracted. He would definitely feel happier but he would be far more unpleasant to live with. He would start to solve cases, devising grandiose complex solutions to the problem and then suddenly become utterly distracted by something else – an experiment he wants to finish or a cadaver that needs dissecting. His life would descend into a chaotic mess if no one is around to assist him.

Alternatively 

Oh and Stephen Fry - he says in The Secret Life of a Manic Depressive (which is on youtube if you haven’t seen it and is fascinating) that he uses his manic periods to work in, because he becomes incredibly creative and can work for long periods of time without sleeping. He’s refused lithium or any mood stabilisers for exactly that reason. It was that documentary that really convinced me about Sherlock. Van Gogh used his manic phases to paint in too didn’t he? Lots of examples through history of people with bipolar who have been incredibly focused during an episode. I think Sherlock’s whole twitchy ‘I need a case, I need a case,’ at the beginning of Hound is the start of a hypomanic episode - he’s irritable, cant stay still, talking too fast, but he knows if he throws himself into a case he can channel it. What if he finds cases when he’s like that rather than v-v?

Kate221B

Sherlock might find his manic episodes very productive. However the majority of people don’t. It’s much easier to be productive during hypomania than it is during mania, if there is no psychotic component. 

Sherlock may also become psychotic during his manic episodes: delusions of grandeur beyond his general egotism. He might believe he has special powers that allow him to see into people’s minds (trust me, as delusions go this one is very sane) or he might get hallucinations.

Otherwise his speech may become so pressured clear associations are lost. Instead of an impressive spiel of deduction, he might just rant incoherently and become angry when people don’t understand. Sherlock may also become much more violent, engaging in physically violent behaviour at slight provocations. 

During these episodes patients tend to increase or initiate illegal drugs. Substance abuse in patients with bipolar is extremely common: either due to his general mania or as a way of calming his overwrought mind (ketamine is a good sedative). I think it is likely that Sherlock started taking drugs during one of his manic/depressive cycles and then just decided he like the effect so much it wasn’t worth stopping.

Depressed Sherlock

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If Sherlock has bipolar: he would actually be clinically depressed – not just sad. He would no longer enjoy solving cases; in fact he would not be able to enjoy anything. He would have very low energy levels so don’t expect him to be bouncing off the furniture or throwing a strop. His personal hygiene would suffer and sleeping patterns will alter. This does not mean he will be an insomniac (there is isn’t any evidence in the show to suggest Sherlock has difficulty sleeping when he wants to sleep) but rather he would have early morning waking, sleep more and feel perpetually tired. Being depressed is draining, and it is usually during the depressive episode that patients seek help from their doctors. However Sherlock, I believe, would rather self-medicate with his own stimulants. This would not solve his problem. Stimulants and sedatives are not anti-depressants; they make you far more depressed after their effects wear off than you were before. This is how people get addicted – because you feel so awful afterwards you need another hit immediately.

In order for antidepressants to work, you have to take them religiously for about 3 months before you can even see a noticeable difference. They are emphatically not “happy pills”, they are mood regulators. If a non-depressed person took anti-depressants, they would not feel any happier.

Social Support

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Bipolar disorder is a very serious illness with high mortality and morbidity. It is also a chronic disorder that has no cure.

If Sherlock has bipolar and refuses to take medication/takes medication sporadically, he would require a great deal of social support. Mycroft is the best candidate. Sherlock suffering from bipolar would go a very long way to explain why Mycroft is perpetually concerned about him and why Mycroft feels the need to keep his brother under constant surveillance.

John is a qualified doctor and can also provide help. As I have discussed in Dr Watson: scientist and psychiatrist: John as a GP would have dealt with many cases of bipolar disorder because it is very common and tends to manifest itself in young adults. However mental illnesses are valid reasons for the army to discharge soldiers and very few soldiers with mental illnesses stay in the army after getting a definitive diagnosis. John would not therefore be involved in the long term treatment of these individuals

John might be able to tell when Sherlock is having a manic episode and he would know how to deal medically with an acute episode: sedatives + a mood stabiliser, but he might not be well versed in the nuances of long term treatment for bipolar. He certainly wouldn’t know how make sure Sherlock takes his lithium because it is a horrible drug and compliance even amongst the non-genius population is pretty low.

There is currently no cure for bipolar disorder. It is a chronic and persistent condition that cannot always be controlled adequately and does wreak havoc in many people’s lives. 

Other Metas in the Series:

1. Sherlock is to Autism as Eeyore is to Depression

Why Sherlock can’t be a high functioning sociopath 

2. Mycroft on the Examination Couch

Is Mycroft the real psychopath in the Holmes family, I get out the official diagnostic criteria and explain some uncomfortable truths about Mycroft and the condition 

3. Sherlock, himself and his Asperger’s

Why Sherlock wouldn’t be diagnosed with Asperger’s Syndrome in the UK

4. Jim Moriarty - Hiiiiii!

Exactly what is wrong with Jim Moriarty