Lack of insight, or anosognosia, affects up to 40% of bipolar patients. Interestingly, it’s caused by damage to parts of the right hemisphere, and makes it impossible for patients to believe they are ill or delusional or hallucinating. It is the biggest reason why people with bipolar and psychotic disorders don’t take their medication.
It was about six or seven weeks from when my mum first noticed the manic symptoms to when I started noticing them. I was vaguely aware of what was going on, that my mood was heightening, that I was behaving out of character, that I wasn’t quite myself- but I didn’t really think it meant I was sick. I’d say that insight during those first few months came and went- at times I could hear my mum, could acknowledge that my friends and people at work were picking up on a change in me, and when my psychiatrist appointment was cancelled and rescheduled for 6 weeks later, I had enough wits about me to insist I needed to be seen sooner. But at times I was, as my work colleagues would joke, living in ‘bubble land’. I struggled to believe my GP when she warned things would escalate, brushed off my family’s concerns, climbed out my bedroom window onto rickety scaffolding in the middle of storm Imogen and failed to see that it was both dangerous and an indication that I was ‘unwell’.
As it had prior to admission, insight came and went while I was in hospital in February. I didn’t totally disbelieve something wasn’t the matter, I just thought everyone was blowing it all out of proportion. I laugh out loud when I’m presented with a form to sign that states ‘DIAGNOSIS: MANIC EPISODE’ and holler that it’s ‘bullshit’ when I’m started on Haloperidol and stand up on my chair in the middle of my admission with the consultant, unaware that everyone in the room is looking alarmed, and I spout ‘nope, not necessary’ each meds time. But I go along with it. I am vocal about the fact that really, this is all very unnecessary, I’m really not manic!- but I still swallow the pills and listen to the nurses when they tell me that it is, and I am, even though I don’t really believe it. And they bring me down and I swing from low to high for a week or so and then I settle in a happy hypo and begin demanding to be discharged so I can go on holiday. My consultant’s stand in lets me, much to the disapproval of the nurses who know me best. So off I go, shopping bag of meds in tow, thoroughly unconvinced that this is a Real and Serious illness that needs to be carefully managed and monitored.
I think I completely lost it one Saturday between admissions. I’d just got back from holiday and I rang the ward, as per my favourite nurse’s instructions, to let her know that I’d taken my meds while I was away. She told me I was high and tried to talk me round when I told her I was magic and no longer needed lithium. And ordinarily, my favourite nurse can talk me down from anything, but that night, it all goes ‘shoooooomp’ in one ear, out the other. I surmise that like everyone else, she’s talking shit.
So I rock up to see the doctor a few days later and ask to be taken off the lithium, and once he speaks to my mum and they establish that I am unwilling and unable to take it on account of the fact that I am NOT FUCKING ILL AND AM PERFECTLY FINE, I am taken back to hospital.
Those first few days, I really, truly can’t believe I am unwell or in need of medication. And the thing is, the mania isn’t fun. I’m having a horrible, horrible time. I am angry and irritable and I cannot cannot cannot sit still. My legs jig/bounce/swing non-stop for two weeks. I have an insatiable need to talk, or sing, or move. There are worms squiggling in my brain, eating me. My brain is working to keep up with my thoughts, that hop, obsess, run round in circles and make complicated links and everything is very confusing and I can’t keep track and I form grand, intelligent theories, but the cogs are getting stuck because they are going so fast and I can’t connect them to make sense! and I focus very hard, thinking the same thought over over over…And I am certain that everyone is working against me and truthfully, at times, it is dark and scary and everything is very overwhelming because part of me knows I am Not In Control, but I cannot cannot relinquish the little control I do have to the people that are trying to steal the Magic!! And dammit, I could feel the magic coursing through my veins! And they want me to take the pills to steal my magic and suppress my intelligence because the government is afraid of what I am capable of otherwise! The nurses, my mum, tell me they can’t all be wrong, to trust them now because I have in the past. But I am indignant, confused, desperately alone, very frustrated. I am me! So surely I should know me best! Why won’t let listen- I am fine!!!
But I am not. Because when I am given leave I stand on the ledge of a window and nearly throw myself out of it, it kind of, sort of, starts to sink in that if I was ‘perfectly fine’, I would not be standing where I was. So I get down and get drunk because I would really rather not think about the fact that not being ‘perfectly fine’ means I probably have bipolar disorder.
So in the same way I am not quite sure when I lost insight, I am not quite sure when it came back. It was the same thing- it came and went. That afternoon standing on the ledge was probably the start of it, but it was another eight days before the mania began to subside. I still climbed the furniature and pulled faces at the staff when they told me I had to get down, still talked and sang incessantly and rolled my eyes when people told me I was high as a kite, still didn’t understand why the nurses sighed when I came up with another Brilliant Idea, still demanded to be let out for walks at midnight and got frustrated when they told me they couldn’t teach me how to take bloods or let me help with the paperwork, still climbed onto the hospital roof and didn’t see what was wrong with doing so. And I still didn’t really buy the whole bipolar/needing lithium thing.
But there were moments of greater clarity and of something that was inching towards acceptance and understanding. One of my favourite nurses told me the mania had reached the point where it wasn’t fun anymore, and I agreed with her. One night after furious pacing of the garden, I came in and asked one of the nurses what if this whole bipolar business was really true- what if they were right and I was sick? By Friday, I am in tears telling the trainee psychiatrist I just want my brain to stop going, my legs to stop jigging, to just be still for five fucking minutes.
And then, the magic and glitter starts to fade away and I can start to see the past five or six months for what they really were- and really, that has only been in the last couple of weeks. I am seeing things that happened in a new light, cringing at things I’ve said and done that were very much out of character. Bit by bit I am beginning to see that my behaviour was ‘inappropriate’, ‘risky’, ‘dangerous’, my mood over the top, brash. I am both mildly amused and a little mortified about my conviction that I was practically already a nurse, could cure other patients of their illnesses, could teach myself to be a neurologist, could bring down a global retail chain and convince Jeremy Hunt that I could single handedly fix the NHS if he just gave me the money. And I’m just a little embarrassed that I suggested, seriously, that we should have a house party one night. This week in particular, after a bit of writing and reflecting, I’m alarmed at just how unwell I was. I said it a few times the last week or two I was in hospital- how strange it is what the brain can do to people, and now that it’s starting to sink in that I was actually very far from ‘perfectly fine’, I resonate with that statement even more.
Close to the end of my first admission for mania, I was talking with a nurse about how I felt I was ‘so settled’ and didn’t need to be in hospital any more, and she said ‘but do you understand why you’re in hospital? Do you see that standing on the dining room table singing Frozen is inappropriate?’ and I said ‘no’, and she said ‘well that’s why you’re still here then’. At the time, I sincerely thought I was ‘stable’ and sincerely didn’t think standing on the table was a Big Deal- people just needed to loosen up. In the following weeks, mum used that as a ‘marker’ to see if I was still a lil’ high and lacking insight.
Honestly, it’s only been this week that I’ve been able to see that actually, standing on the dining room table singling Frozen probably wasn’t appropriate- and truthfully, I’m a little embarrassed that I ever thought it was. Gaining insight has been gradual and ongoing, even weeks after my mood has levelled out. Getting well and realising how unwell I was has left me feeling a little uneasy, and more than a little scared of my brain and this illness. So I probably do need the lithium…