Bipolar Disorder

Excerpt from:  WHY YOU DO THAT, by John B. Evans, PhD, LCSW

Bipolar disorder is a mood disorder rather than a personality disorder, and occurs at multiple levels of severity. Bipolar Disorder, also referred to as manic depression, involves mood fluctuations between a manic (hyper) state and a state of depression. Either a manic episode or depressive episode may cause serious impairment in work, social life, etc. There may be psychotic features in the more severe cases, and hospitalization may be necessary in some cases. Other cases may be very mild and go undiagnosed and untreated for years or for an individual’s entire life. These traits are found in both men and women. 

     Bipolar disorder involves episodes of mania and episodes of depression. The bipolar individual will typically alternate between these states for varied periods of time, although in some cases, there may be a mix of both the manic and depressed states simultaneously. Mania may occur in either the euphoric style or the irritable/anger style, although in some cases, there may be a simultaneous mix of both manic styles. 

MANIA: Mania usually appears in two basic forms: 

1. Euphoria
2. Irritable / anger 

EUPHORIC MANIA: Unusually cheerful or euphoric mood characterized by:

• Hyper thinking with racing and scattered thoughts and a flight of ideas 
• An increase in energy or activity level
• Feeling agitated or restless, and possibly exhibiting behavior that appears to have no reason or purpose 
• The uninteresting becomes interesting 
• Excessive talking / hyper speech / frequent shifts in topic 
• Increase in goal-directed activity whether work, social, academic, or sexual in nature 
• Reduced need for sleep 
• Increase in self-esteem and self-confidence, sometimes referred to as grandiosity / no shyness 
• Impulsivity / quick decisions that are not thought out 
• Easily distracted 
• Easily bored / quickly focuses on something new 
• Shopping / spending sprees 
• Entertaining / witty / life of the party 
• Less emphasis on ethical decisions 
• Sexually promiscuous / wants to seduce or be seduced 
• Alcohol / drug abuse 
• Feeling of power 
• Increase in creativity 

IRRITABLE / ANGER MANIA 

• Easily irritated / moody 
• Numerous complaints 
• Quick and unpredictable anger / hostility 
• Excessive anger displays / recites a litany of accusations 
• Highly irrational when angry / logic may disappear completely
• No sense of fair play when angry 
• You cannot talk to them when angry / they cannot hear you 

     Manic episodes are frequently described as euphoric, unusually cheerful, or a high feeling with excessive and exuberant energy. In the euphoric state, there may be an increase in activity in multiple areas including work, social, academic, religious, political endeavors, etc. A high level of self-esteem and self-confidence, referred to as grandiosity, may be present. With excessive self-confidence, the manic individual may pursue multiple projects, one after the other, even if he is knowledgably deficient in these areas. The high self-esteem and self-confidence may become delusional in some cases. In a euphoric state with an excess of optimism, the manic individual may have a loss of insight and show poor judgement with money, business and investment decisions, sexual promiscuity, reckless driving, gambling, giving away possessions, antisocial and illegal behavior, etc. Rapid speech and/or overly loud speech may be present, such that the individual is difficult to interrupt and converse with. The individual may shift from one topic to another in an unnatural flow of irrelevancies as the individual is distracted by the slightest thought or stimulus. The individual may appear to have difficulty keeping up with his own flow of thoughts and ideas. An almost theatrical “life of the party†presentation of jokes and witticisms may be present. 

     In some cases, the predominant manic mood may be irritable and angry rather than expansive and euphoric. Rapid shifts between states of euphoria and irritability may occur in short periods of time, and this may occur with little self-awareness by the individual involved. With irritable/anger mania, criticisms may predominate. A rational conversation with someone in the manic anger state may not be possible. It is common for the manic individual to feel a marked decrease need for sleep, and they may say they feel fine after only a couple of hours of sleep each night. In more serious cases, the individual may go for days without any sleep and say they feel fine. A decreased need for sleep may indicate a manic episode is about to occur, and it is common for a manic episode to occur just prior to an episode of depression. There can be a simultaneous mix of depression and manic symptoms, and this may last from a few moments to a few days. 

     Over ninety percent of individuals who have one manic episode will have multiple episodes, and four or more manic episodes in one year is defined as “rapid cycling.†Hospitalization may be necessary in some severe cases to protect the manic individual from self-harm or injuring others. The manic individual may not recognize their manic state and may resist treatment. 

     In children, being excessively happy and silly with an increase in energy and hyper-activity is normal in some contexts, but if these behaviors are out of context and recurrent, consultation with an expert is recommended. Like manic adults, some children experiencing mania may have elevated self-esteem and be overly self-confident, such as believing they are the smartest or the best at some sport, or invincible, which may result in attempts at dangerous feats. The child may start making plans for multiple projects or have unusual sexual preoccupations. 

HYPOMANIA (Mild Mania): A hypomanic episode is similar to a full manic episode, but with fewer symptoms and for a shorter period of time. The hypomanic period may cause distress and dysfunction in the individual’s work, social life, etc., while in other cases, the hypomanic individual may be able to function well enough to get by on a day-to-day basis, although with greater effort and possibly a reputation for instability, moodiness, unreliability, being erratic, etc. 

DEPRESSION: Depression occurs at multiple levels of severity from mild depressive symptoms through the much more severe major depression. There are multiple symptoms associated with depression: 

• The individual reports feeling depressed, which may include feeling sad or hopeless, or other people may say the individual appears depressed with symptoms such as crying, etc. 
• Loss of interest and pleasure in most or all activities 
• Loss of appetite with weight loss or increase in appetite with weight gain 
• Sleeps too much or too little 
• Feeling agitation and restlessness 
• Feeling tiredness and loss of energy 
• Feeling worthless 
• Feeling guilty 
• Hard to think or concentrate 
• Indecisive 
• Recurring thoughts of death, which may or may not include thoughts of suicide
• Children may appear irritable or bored 

     It is important to remember that antidepressants may cause or increase the severity of a manic phase. Individuals who begin taking antidepressant medications during a period of depression, without knowing they are bipolar, may exhibit manic symptoms with no awareness of the cause of their manic symptoms. A comprehensive evaluation by an expert may help avoid this reaction. 

Bipolar disorder occurs in three basic forms: 

BIPOLAR I: Bipolar I disorder involves the more extreme levels of mania, and the individual will typically fluctuate between mania and some level of depression. The depression in bipolar I usually involves the more serious major depression, but may be a milder depression in some cases. The more severe major depression is not required for a diagnosis of bipolar I. 

BIPOLAR II: Bipolar II involves a milder form of mania, called hypomania, which involves fewer and less severe symptoms, and the symptoms are usually of shorter duration than found in a full manic episode. But the depression in bipolar II is always the much more severe major depression such that, even with the milder hypomanic episodes, the overall suffering of the bipolar II individual may be as severe and cause as much distress and impairment as experienced with Bipolar I. The major depression associated with bipolar II may occur more frequently and be of longer duration than in bipolar I, so the bipolar II individual may suffer for longer periods of time than the bipolar I individual. So bipolar II is no longer viewed as a less severe version of bipolar I because major depression is not required for a bipolar I diagnosis, but is required for a bipolar II diagnosis. The milder hypomanic episodes in bipolar II may not even be viewed as a problem by the sufferer, although other people may not like the erratic behavior displayed during the individual’s hypomanic episodes. 

     When bipolar II individuals experience a simultaneous mix of both depression and hypomania, they may only recognize the depression, but with a higher level of energy or irritability. Some bipolar II individuals will have periods of relative normalcy between mood episodes, while others may have some residual dysfunction between mood episodes, or just transition directly into another mood episode with no between episode recovery. The bipolar II individual may have experienced several episodes of major depression prior to the onset of hypomania. 

     One of the strongest risk factors for bipolar disorder is a family history of bipolar disorder. Adult relatives of individuals with bipolar I or bipolar II disorders are 10 times more likely to experience bipolar disorder than the general population. The first onset of bipolar disorder can occur at any time during the life span, including in the 60s or 70s. Any level of bipolar disorder must be taken very seriously since the risk of suicide is 15 times that of the general population. 

CYCLOTHYMIA (Mild Bipolar): Cyclothymia is a mild form of bipolar disorder and involves mood fluctuations between mild depression and a mild hypomania that is even less severe than the hypomania associated with bipolar II. Cyclothymia may be misdiagnosed or go undiagnosed for years or for an individual’s entire life. What follows is an extended review of cyclothymic symptoms and patterns of behavior. Anyone relating to any aspect of this chapter is encouraged to read the chapter: Mild Depression. 

     While the mood symptoms are milder with cyclothymia than with bipolar I and bipolar II, the cyclothymic will experience some distress, impairment and dysfunction in their work, social, academic life, etc., although their distress and impairment may not be severe enough to keep them from functioning adequately enough to get by from day to day. The unpredictable cycling between the hypomanic and depressed states may give the individual a reputation for being unpredictable, moody, temperamental, unreliable or erratic in their responses to life circumstances. It is common for the cyclothymic to eventually develop bipolar I or bipolar II disorder. 

     During the hypomanic phase, the cyclothymic may experience either the euphoric or the irritable/anger style of hypomania, or they may alternate between these two basic styles. In some cases, there may be a mix of the euphoric and irritable styles at the same time. 

     In the euphoric hypomanic state, an individual may use his higher energy level to plan and work on numerous projects or hobbies, but complete few of them because he gets distracted by other projects that appear more exciting, or are just new and different. Along with a higher level of energy and activity, there may also be an increase in self-esteem and self-confidence, and this may lead to an increase in occupational or social interactions with other people. In this mild euphoria, the cyclothymic may be quite entertaining, with an emphasis on nonstop wit, including jokes, one-liners and general hilarity. He may have a reputation as the quintessential life of the party. Impulsivity may show up in poor judgment, such as poor investment and business decisions, irrational shopping, or irrational fantasies and sexual activity. With instant decisions that have little forethought, ethical issues may take a backseat to what looks desirable, fun, or just feels good. 

     These behavior patterns may occur as the cyclothymic survives on just a few hours of sleep per night. This mild euphoria may feel good to the cyclothymic, and they may deny that anything is wrong⁵⁴ and be resistant to treatment. I have found individuals exhibiting euphoric hypomania, as well as those presenting a more severe mania, to be similar to cocaine or methamphetamine addicts who do not want to give up the wonderful drug-induced euphoric feelings, even though the symptoms are causing severe problems in their life. 

     The racing mind and hyper thinking of hypomania may also show up as irrational irritability, complaining, hostility, and anger. In some cases, the anger outbursts may be severe. In the irritable state, it takes very little to upset the cyclothymic and misunderstandings may be routine. Once a cyclothymic is pissed off, expect his logic and reasoning ability to exit the conversation, almost completely in some cases, and children may be severely punished for minor infractions. At this point, any discussion or argument with the cyclothymic will be very one-sided as far as any exchange of information. With his mind racing, the cyclothymic may rant and rave to the exclusion of any real listening to the opposing view. Any sense of fair play in the discussion may be lost, and the chance of actual communication may require an extended breather while the cyclothymic calms down. 

     Some cyclothymics may function adequately during their hypomanic periods, especially those experiencing the euphoric style of hypomania. The euphoric style of hypomania may generate considerable creativity and positive social activity, but may also cause the hypomanic to blurt out the wrong thing and offend others, or just appear awkward and eccentric. It is the unexpected shifts into irritability and anger that give the cyclothymic a reputation for being unpredictable, moody, or temperamental. Hypomania may last for hours, days, weeks, or months, but in most cases the individual will eventually revert back to a state of mild depression with the symptoms associated with this mood state. As with personality styles and disorders, individuals with unstable and shifting moods may not even be aware that they have a problem, or there may be some denial about the severity of the symptoms. 

     Cyclothymia usually appears gradually, beginning in childhood. This gradual onset appears to mask the growing instability to other family members who gradually become accustomed to the cyclothymic’s erratic behavior. Depression may appear first, with the child initially becoming irritable or bored since this is how depression may appear in children. Hypomanic symptoms, such as euphoria, hyperactivity and/or anger outbursts may appear later, although children in the hypomanic state are more likely to display irritability and temper tantrums instead of euphoria. Children and adolescents may experience several mood swings in one day. 

     There is a greater frequency of mood disorders among the first- degree relatives of cyclothymic individuals. Even when there is not a clear history of mood disorders in the family, sufferers of cyclothymia may have been raised by parents with erratic behavior, such as mood swings, irrational thinking, temper tantrums, criticisms, excessive punishments etc. The cyclothymic may recall having witnessed, or heard stories about, relatives exhibiting similar behaviors. The vicious circle that is created in some extended families is obvious. The child with cyclothymia, or some other personality style or disorder, may be raised by a temperamental, critical and irrational parent, resulting in a severely neurotic child who evolves to become a very dysfunctional parent to their own children. 

     With its typically mild nature and similar symptoms with other personalities, cyclothymia can be difficult to spot without a good understanding of the symptoms involved. As with many difficult personalities, cyclothymics may spend a lifetime never knowing the source of their eccentric, erratic, irrational, or angry behavior. They may always blame another person, group, or something in the environment for their emotional and behavioral reactions. Some cyclothymics may never even recognize their behavior as odd or irrational. Another problem is the considerable overlap of symptoms between cyclothymia and other disorders, most notably attention deficit hyperactivity disorder (ADHD). Many symptoms of ADHD may be the same symptoms experienced with bipolar disorder, including distractibility, racing thoughts, rapid speech, reduced need for sleep, impulsivity, etc. But in bipolar disorder, these symptoms occur during distinct manic episodes instead of the ongoing symptoms with ADHD. Consultation with an expert is strongly recommended. 

     A correct diagnosis is most important with any level of bipolar disorder, including cyclothymia, since antidepressant medications may precipitate or drastically increase manic symptoms in cyclothymic or bipolar individuals who begin taking antidepressant medications during a depression phase without recognizing they have some level of bipolar disorder. Anyone taking antidepressants and experiencing an increase in manic symptoms at any level, whether euphoria, irritability/anger, or some mix of these symptoms, should immediately consult their doctor or a mental-health professional. 

Cyclothymia in Relationships 

     The mood shifts in cyclothymia may appear in a wide variety of behavioral patterns and variations. Either the mild mania (hypomania) or the mild depression of the cyclothymic may last for hours, weeks, or months, after which the cyclothymic may then shift into the other mood state. 

VIGNETTE: The Unpredictable and Erratic 

     Kyle is a 33-year-old graphic artist and has been married to Ann for six years. They have two young children. Even before they had children, Kyle would sometimes shift from being in an extremely good mood to a bad mood over trivial issues, or for no apparent reason at all. Kyle’s erratic behavior seemed to increase after they had children. Kyle had also cheated on Ann on one occasion, but that was not why Ann sought couples counseling. Ann finally insisted on counseling because of the severe, sometimes brutal, way her husband had punished their children, usually for minor infractions. Of course, Ann was not happy with the way Kyle sometimes treated her either, but Kyle had always told Ann that it was her emotional distance that caused their marital problems, and Ann admitted having bought into this explanation. 

     At the same time, Kyle admitted his unpredictable behavior was sometimes a problem. Kyle admitted that he would sometimes become distant and irritable, and occasionally would go into a rage, during which it was impossible for Ann, the children, or anyone else to talk to him until he had time to calm down. Unfortunately, by the time Kyle settled down, the damage had been done. Either Ann had been irrationally criticized and, on one occasion, pushed to the floor, or the children had been severely punished or reprimanded for minor infractions. Kyle also admitted that his erratic behavior had contributed to his losing some jobs. He always seemed to do well when he was first hired, but eventually Kyle would become irritable with his coworkers or his boss. If he made it to a position of authority, Kyle would needlessly reprimand employees for minor mistakes and occasionally fire some innocent victim. What Ann never understood was how Kyle could sometimes be such a fun, energetic, and witty person, even for an extended period of time, and then quickly shift into irritability or outright hostility over nothing. 

     While Kyle could be the quickest wit and the life of the party, he could also be irrational during his fun, energetic, periods. Kyle would typically become very impulsive during these good times, usually in terms of spending money beyond their budget on expensive toys. He would also become very talkative and more flirtatious at social gatherings. Kyle would also go through periods of constant activity, during which he would become absorbed in various unfinished projects, such as working every day on the old Volkswagen convertible he had wanted to restore for years but just never could stick with long enough to finish the project. Most of the time, the car just took up space in the garage, while Kyle sat in front of the TV every evening drinking beer. When Kyle was not silent, he was usually criticizing some person, object, or event. Since Kyle had usually been willing to apologize for his worst behavior, Ann had hoped that Kyle’s good periods would become the norm. Unfortunately, the critical and emotionally volatile Kyle would always return at some point. 

     Counseling sessions with Kyle and Ann seemed to go well at first, with both of them feeling good and somewhat optimistic about making changes in their family life. Unfortunately, Kyle’s mood shifts began to affect his willingness to continue in therapy and do his part. Ann would come in complaining about Kyle’s behavior, and Kyle would suggest that the counseling sessions were just not working and question whether they should continue spending money for therapy. What Kyle and Ann did not know, and their previous therapists had missed, was that Kyle was cyclothymic, and the shifts in his personality and behavior were not the products of conscious choices or logical thinking. 

     Shifts between mild depression and hypomania may be obvious to those around the cyclothymic, or the changes may be more subtle and less noticeable. The depression stage of cyclothymia will present a whole different set of problems for the relationship and the family, as described in the chapter about mild depression. There may be periods when depression and hypomania seem to be intermixed. While unpredictability of response is the norm when living with a cyclothymic, a simultaneous mix of depression and hypomania may cause the cyclothymic to repeatedly catch other family members by surprise. Within the hypomanic state alone, there may be a simultaneous mix of both the euphoric and the irritable/angry hypomanic styles. A simultaneous mix of mood states creates a chaotic household that further damages the family as a whole, especially the children. With a simultaneous mix of mood states, the partner and children can never be certain which cyclothymic will be encountered at any given moment. There may also be periods of relative normalcy when the cyclothymic is shifting between mood states and, once again, gives the family hope that a real change has come over the cyclothymic. Of course, when the cyclothymic makes a shift between mood states, the family’s responses to the cyclothymic must also make a shift—without advance notice. 

     When euphoric, the racing mind of the cyclothymic may have thoughts and ideas scattered all over the place, and this can be difficult and tiring for other family members, especially the children. While the euphoric cyclothymic may be in a good mood and somewhat energetic and hyperactive, logic and rationality may elude her as she draws quick conclusions and makes unwise decisions with little forethought. Since anything can interest the euphoric hypomanic mind, the cyclothymic’s partner may be simultaneously bored and tense from endless conversations that do not appear rationally directed. 

     The high self-esteem and self-confidence associated with the euphoric style of hypomania may give the cyclothymic the conviction of complete certainty in thought and action. The cyclothymic may argue forcefully to win her point, with little attention paid to the partner’s or children’s opposing views. The cyclothymic’s excessive talking and hyper speech, with little logic accompanying her complete certainty, may quickly wear down the partner’s patience and leave the children with a sense that something is just not right. The children of a cyclothymic may grow up with a sense that what they think does not matter. When the cyclothymic is in the hypomanic state, there may be few periods of peace and quiet, since the cyclothymic may need very little sleep to get by. At times, the partner and children of a euphoric cyclothymic may feel neglected as the cyclothymic puts most of her energy into one project after another, with little attention paid to her partner and children. Affairs may occur due to the irrational impulsivity to which cyclothymics are prone. 

     There may be periods when the euphoric style of hypomania makes the cyclothymic fun to be around. The cyclothymic may be witty and entertaining, and the family may develop a circle of friends who are drawn to this interesting and humorous side of the cyclothymic. Unfortunately, it will usually be a matter of time before the cyclothymic, lacking in self-awareness, makes a serious social blunder. With little shyness or sense of decorum, and a tendency to just blurt things out, there may be embarrassing moments when the cyclothymic makes inappropriate remarks to friends and acquaintances. With the cyclothymic being unpredictable and eccentric, the couple may find friends distancing themselves, while few invitations to social events arrive in the mail. 

     Chronic financial difficulties may plague the family of the cyclothymic. Since hypomania lends itself to quick and impulsive decisions that are not thought out, there is always the danger the cyclothymic will make irrational business or investment decisions, or go on impulsive buying sprees that leave insufficient funds for family expenses. Of course, financial problems get much worse if the cyclothymic gets fired from his job for erratic behavior or just impulsively quits. In the hypomanic state, the racing mind of the cyclothymic is easily distracted away from important family concerns. 

     The cyclothymic may become moody and irritable over insignificant events, and the partner may have to listen to the cyclothymic complain about his job, boss, coworkers, the partner herself, the children, or any other aspect of life. Misunderstandings may be common, and the partner may find it difficult, if not impossible, to discuss anything with an irritable or angry cyclothymic. The partner of the cyclothymic may find her own reasoning and opinions simply have no impact on the cyclothymic’s rants and raves. The partner may find it difficult to tell whether the cyclothymic has slipped into highly irrational thinking or just does not care about fair play where the partner or children are concerned. Expect the children of an irritable/angry cyclothymic to live with anxiety and a sense of foreboding of the criticisms and punishments to come. Of course, when the cyclothymic reverts to a state of depression, a whole different set of symptoms will present itself (see chapter: Mild Depression). Families with a cyclothymic member may go for years, decades, or possibly never recognize the source of the chaos that routinely invades their home. The cyclothymic may always be able to explain his erratic or eccentric behavior to his own satisfaction, and the partner and children may buy into his explanations, even when his behavior borders on abuse (see chapter: The Abusive Personality/Abusive Relationships). 

NOTE: It is common for other disorders to co-occur with bipolar disorders with anxiety disorders being the most common, and an anxiety disorder may have been present prior to the onset of bipolar disorder. Panic attacks, shyness, sleep disorders, phobias, impulse-control, conduct disorders, substance abuse and other disorders may also co- occur with bipolar disorders. More than half of those with bipolar disorder have some level of an alcohol use disorder. Consultation with a professional is strongly recommended.