Dr. Suzanne Flala has always been a high achiever. When she graduated from medical school she received an award for excellence in her clinical work. She was appointed chief resident of her residency program. Her reputation in the field is outstanding, and she is renowned for the compassionate manner in which she treats her patients. And, yet, something is wrong. In a moving essay published in the Journal of the American Medical Association she writes:

I live in a different world. I go through the same motions as others: I wake, relate, and work. But my life plays out in a different theater. The on-stage me is an illusion. The actor is friendly and outgoing, provides good patient care in a group practice, and successfully juggles the rigors of home and career as a single parent. She appears to live a hectic but happy life, and manages to do it with efficiency and grace. [But] I have Bipolar disorder: manic depression. Normal is a place I visit, not one in which I am allowed to remain.

Flala’s essay speaks to the struggles of living with high-functioning bipolar disorder: functional enough to create and maintain an illustrious career, care for her daughters, and forge a few close friendships, not functional enough to feel free from the illness that plagues her. Her story is one shared by many, remains largely invisible when we talk about bipolar disorder, and acts as a reminder that functionality does not mean the end of suffering.

Acknowledging High-Functioning Bipolar Disorder

In the vast spectrum of mental health disorders, bipolar disorder is generally considered to be “serious.” In our cultural mythology, people with bipolar disorder have extreme manias that scream their illness for everyone to hear and deep depressions that render them immobilized. While they are imagined to excel in the arts, few expect to encounter the physician, the lawyer, the c-suite executive with bipolar disorder. The illness is often thought to be so consuming that it fundamentally fractures one’s ability to function at the level needed to achieve success in the traditional workplace.

However, bipolar disorder is experienced and handled by people in infinite ways and high-functioning bipolar disorder is a reality for many. You can care for yourself, you can engage socially, you can keep and even be exceptional at your job. Sometimes, this high level of function is the result of successful treatment; many people with bipolar disorder can live full, rich, and productive lives with appropriate supports. Sometimes, however, functionality is a survival mechanism, barely letting you keep your head above water as you navigate the obstacles of your illness.

The Burden of Maintaining Function    

For many, high-functioning bipolar disorder isn’t simply a natural state, but the result of hard work. Maintaining functionality is not necessarily a comment on the severity of your symptoms, but on the fact that you have created mechanisms for yourself to suppress them, work around them, or compensate for them, even in deeply painful moments. Often, these mechanisms are targeted toward one area of your life and developed not to alleviate the distress of your symptoms, but to power through them for the sake of functionality itself—they allow you to keep the job you need to support yourself, do what you need to do to care of your family, or keep your illness hidden from view.

“If my colleagues knew I was bipolar, I fear that I would never again be taken seriously, that I would be viewed as the ‘impaired’ physician who, at the display of passion or emotion, would be seen as having an ‘episode,’” writes Dr. Flala, who can count on one hand the number of people to whom she’s disclosed her illness outside of her family. “My right to express even normal anger or irritability, happiness, or my effervescent sense of humor would be suspected as pathological. I would lose the right to just have a bad day.” She exhausts her emotional resources in order to keep not just the professional reputation she has earned, but her basic dignity.

For writer Natasha Tracy, functionality is more focused and forged for the purpose of being able to pay the bills. “Sometimes people don’t believe I’m particularly sick. They meet me, I look fine, I interact, I charm, I with, and all seems normal,” she says. “And that’s fine. It’s by design.” Her guise of normalcy allows her to dedicate herself to her job, stay on top of her workload, and keep her clients happy.

The trouble is, using all my control, sanity, and energy during the week to try and produce enough work to pay my rent leaves me with a large deficit when I’m not working. All the appearance of my [professional] functioning is paid for by utter decimation and exhaustion the rest of the time. So yes. I’m capable. I’m talented. I work hard. I produce stuff. But the price I pay for that is not being able to do anything else.

For Tracy, functionality isn’t a form of self-care. It’s not proof that she is doing well or that her symptoms aren’t severe. In many ways, she is simply re-scheduling those symptoms in order to get by and foregoing meaningful social relationships as a result.

The Dangers of High-Functioning Bipolar Disorder

While maintaining high function can have professional and social benefits, it can also come with significant dangers. Just as functionality can be used to keep the existence or severity of your bipolar disorder from others, it may also keep it hidden from yourself. You may take your ability to work, to socialize, to participate in everyday life as a sign that you don’t need treatment or that treatment is working, even when your symptoms are just being pushed under the rug rather than actually improving; temporarily staving off functional disruption isn’t the same as healing, and working so hard to maintain function in one area can leave you without resources to devote to other vital parts of your life. At other times, what is interpreted as high functionality may, in fact, be symptoms of the illness; the increased energy, sense of possibility, happiness, and flourish of ideas that seemingly enhance your professional and personal life could be signs of mania or hypomania. Left unabated, these episodes may not only be destructive in and of themselves, they may also instigate mood switching and contribute to long-term changes in the brain. 

Hiding your bipolar disorder by masking its symptoms also has another disturbing effect; it can keep you from developing a strong social support network in which you can freely express your thoughts, feelings, and experiences. Research proves again and again that people who have high-quality close relationships have better outcomes and fewer recurrences than those who do not. While there are certainly very real risks associated with disclosing bipolar disorder—particularly in professional environments—keeping yourself isolated within your illness is also a dangerous endeavor. Being able to be open about your illness, give voice to your distress, and feel heard and validated by people who care about your is imperative to the healing process.

When to Seek Treatment for High-Functioning Bipolar Disorder

If you are living with high-functioning bipolar disorder, it can be tempting to convince yourself that you don’t need help or that the help you are receiving is adequate. And, indeed, for some people, high functionality is reflective of successful treatment rather than forcefully pushing away symptoms to get through the day. However, it is vital that you examine your functionality closely to distinguish between actual improvement of symptoms and masking of symptoms. If you determine that your high function is a temporary coping mechanism rather than the result of alleviated symptoms, it may be time to seek more intensive treatment.

For many people with high-functioning bipolar disorder, residential treatment programs offer the best environments to begin the recovery journey. The ability to get away from pressures and responsibilities gives you the time and space you need to let your guard down and allow yourself to feel your feelings without the need to push them away or plow through them to get on with your day. Acknowledging the true extent of your illness and living through your symptoms honestly can be frightening and painful, but it can also be deeply relieving to stop running and express your true emotions. Not only is this essential to acknowledging your authentic self, it is also a vital part of the assessment process; in order for treatment to work, your clinical team must have a clear view of your symptoms, unhindered by a façade of functionality.

Once your clinical team has a fully developed picture of your symptoms and personality, an individualized treatment plan will be created to address your specific needs using a comprehensive curriculum of therapies that open up multiple avenues to healing. These include both individual treatment modalities as well as group therapies that give you the opportunity to share with and learn from peers who understand what you are going through and support you through your recovery process. Additionally, family and couples therapy provides you with a safe space to strengthen your most important relationships and develop deeper bonds.

Throughout the treatment process, you will gain the insight and skills to gain true functionality rather than using functionality as a way to camouflage your distress. While bipolar disorder is a chronic illness that will require ongoing management, you can create a strong foundation for wellness that can buoy you throughout your life and open up the door to newfound joy, stability, and emotional harmony.

Bridges to Recovery offers comprehensive residential treatment for people struggling with mental health disorders as well as co-occurring substance abuse and eating disorders. Contact us to learn more about our renowned Los Angeles and San Diego-based programs and how we can help you or your loved one start on the path to lasting wellness.

Image Source: Unsplash user Thomas Hafeneth

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