With last week’s Moon Knight #188, everyone’s favorite mentally ill vigilante is back. Or, at least, we get to meet his new arch-nemesis. While Marc Spector is famously afflicted with Dissociative Identity Disorder, this new antagonist displays bipolar. Sort of. AiPT! once again enlists our contributing psychiatrist, Richard Schloss, to see how writer Max Bemis did in portraying this real disease.

Before 1980, what we now call Bipolar Disorder was known as “Manic Depression.” While felt to be somewhat pejorative, the older term is highly descriptive: a condition marked, as Dr. Emmett notes in the issue, by excursions into both mania and depression. Everyone thinks they know what depression is (although most would be at least partially wrong), but what’s mania?

It’s a state in which everything is “revved up.” The person with mania has lots of energy, sleeps very little yet is not tired, and engages in multiple activities. That doesn’t sound so bad, right? And in fact, there is a state before mania, in which people feel energized and may be highly productive, called hypomania, meaning “below mania.” But no one can remain in a hypomanic state indefinitely, with the possible exception of Richard Branson.

The problem with mania is that it’s well beyond anything you could get by drinking a few large cups of strong coffee. The afflicted individual talks rapidly (a symptom called pressured speech), and often cannot get their thoughts to slow down (referred to as flight of ideas). They will engage in potentially dangerous behaviors, such as driving too fast, experimenting with illicit drugs, or being sexually promiscuous. They will overspend on unaffordable luxuries to the point of impoverishing themselves. Women with responsible jobs will start dressing inappropriately and provocatively at work. They lack insight, and when challenged will project that it’s the others who doubt them, not they themselves, who are mentally ill. Marital strife is common.

The cliché is that manic patients are having a grand old time, but more often they are simply irritable and quick to anger, or even combative. Not surprisingly, people in manic states not infrequently run afoul of the law. At its most severe, mania produces actual psychotic symptoms; sufferers will express delusional beliefs that they have special abilities or powers, or that they are on a direct mission from God (a state known as grandiosity).

Even though a single manic episode is sufficient to make the diagnosis, the hallmark of Bipolar Disorder is not mania, but cycling: oscillation from depression – where bipolar patients spend about two-thirds of their time – to mania, and back again. It is that “crash,” when mania suddenly converts to depression, that is the most dangerous phase of the illness, in that the risk of suicide peaks at that point.

What must be emphasized is that Bipolar Disorder is a genetically determined, neurochemical disorder of the brain. Having one parent with Bipolar Disorder increases the risk of developing the illness significantly, and having two bipolar parents (a fortunately rare situation) would make the chances of also becoming bipolar very high indeed. Early childhood trauma cannot make someone without the underlying genetic risk for developing a mood disorder “become” bipolar. It is thought that significant stress can trigger an episode of mania or depression in a patient with the genetic predisposition, but they would have gone on to develop signs of the disorder at a later date regardless.

Symptoms typically begin to express themselves in early adulthood – usually in the 20s, earlier than what is seen with unipolar depression. Nevertheless, the first symptoms of Bipolar Disorder are often depressive rather than manic, leading to frequent misdiagnosis as unipolar depression, and to incorrect treatment with antidepressants rather than mood stabilizers, sometimes for years at a time.

Bipolar individuals are sometimes very creative, artistic, and innovative, particularly during the hypomanic phase that precedes full mania. The late Carrie Fisher was diagnosed with Bipolar Disorder after going through several stints in rehab for alcohol and substance abuse. Carrie’s father was the 1950s singer Eddie Fisher, who was almost certainly bipolar, and may have divorced Carrie’s mother Debbie Reynolds to marry Elizabeth Taylor during a manic episode.

Carrie related the following anecdote during one of her personal appearances. She had just informed her mother of her new diagnosis of Bipolar Disorder, and the reaction was, “Well, where would you get a thing like that?” Carrie explained that she had probably inherited it from her father, which puzzled Reynolds: “I don’t remember anything like that,” she said. Carrie pointed out to her that Fisher had often exhibited manic behavior, such as that time when he bought 1,000 suits. Reynolds thought this over very carefully. “Oh, so it’s a Jewish thing,” she concluded.