A Fresh Perspective on Bipolar Disorder
by Dr. Dan Bochner
It's a matter of intensity! It's really as simple as that. Bipolar disorder has many faces, and gets involved in so many other mental health issues, that it often seems quite complicated. Individuals with personality disorders are frequently very intense, and they often end up being given the bipolar diagnosis. Individuals who become psychotic (which means they lose touch with reality) often do so partially because of their intensity. Sometimes it's hard to tell the difference between the impulsiveness involved in hyperactivity, autism or post-traumatic stress disorder, or even mental retardation, and the impulsiveness related to bipolar disorder. The fact is that moodiness and intensity are so often a part of other diagnoses that understanding bipolar disorder, and understanding how bipolar disorder can be a part of other diagnoses, is necessary in understanding psychopathology itself.
A person's intensity affects how they react to everything they experience. The stronger a person's feelings are, the harder it is for that person to modulate those feelings. The bipolar can feel intensely depressed, intensely nervous, intensely excited, or intensely angry. Sadness becomes overwhelming rumination, anxiety becomes panic, and anger becomes rage. Feeling good becomes a flood of intricate, but often loosely connected, brilliant ideas, or a desire to save the world, or the feeling that one can fly.
The best way to think about the intensity of the bipolar individual is to understand that the reptilian part of their brain is far too powerful. Neuroscience suggests that the lower parts of the human brain appear to be just like those of lower animals. That part of the brain handles automatic functioning and is largely based on the animal's need to stay protected and find sustenance. When a reptile fears a predator it has to ready itself for fleeing, fighting or freezing. When a reptile feels hunger it has to find something to eat. The higher brain, or cortex, modulates the lower parts of the brain. We use our understanding of things to mitigate the strength of the lower brain. However, the reptilian brain can have such intensity that it overwhelms the cortex. Or, conversely, the cortex can be underdeveloped in some ways, limiting the extent to which it sufficiently modulates the intensity of the lower brain. In bipolar disorder, the intensity of the lower brain is not adequately modulated which makes the bipolar behave at times like a T-Rex, vicious and starving, and at other times like a frightened little rabbit, jittery and afraid. If one can express an experience in terms of hunger and satiation on one hand, or fear and self-protection on the other, then it's an experience that will express itself intensely, behaviorally speaking, in the actions of the bipolar.
Individuals with bipolar disorder are known to buy impulsively, as if their hunger for material possessions can't be sated. Similarly they often desire sexual activity and find themselves unable to control their passions regardless of the consequences. Anyone with bipolar disorder has had problems in controlling what they want. They react to what they want as though they need it desperately. They often want it right now, and they have a hard time really differentiating wants from needs. With respect to their hunger for things, or affection, or control, or any other kind of desire, the bipolar behaves as if they have been starved for years and will perish immediately unless sustenance can be found (please see article, The Power and Control Addiction).
Likewise, the bipolar reacts to threats of any kind in extremely exaggerated ways. If they're cut off on the road, the bipolar may go into a “road rage.” Alternatively, they might develop a phobia to driving or to the area on the road where they were cut off. When it comes to interpersonal threats, the bipolar reacts with venom and aggression or with desperate fear. Where your average person might get miffed at a friend and decide to say nothing in spite of holding back some rankling emotions, the bipolar likely tries to cut the friend down to size and may just end up cutting off the friendship altogether. When in a dating situation, your average person might react to the ogling of one's partner with anger and an admonishment that it should never happen again, holding off judgment as to whether it might be a real problem. The bipolar is likely to slap or punch or verbally bash their date and/or the person who was ogled, thus requiring some kind of outside intervention, even if it's the first time it has happened. People with bipolar disorder often have problems in controlling the extent to which they feel threatened, and thus the extent to which they react to such threats. With respect to their need to protect themselves from competition with others, people bossing them around, the feeling that someone might be insulting them or might be trying to get one over on them, the bipolar behaves as if their very existence hangs in the balance. And if they do not bolt off or violently attack, they appear to feel like they might just be viciously torn limb from limb at any moment.
Dominance and submission often become the theme where bipolar disorder is concerned. Even where most people would understand that everyone determines their own fate and that no one controls anyone else, someone with bipolar disorder is quite likely to behave as though they must end up on top or they might lose their very life. They are extremely sensitive to criticism, control, attitude, slights, being ignored, etc... all of which make them feel downed, and all of which are likely to result in aggression or severe anxiety or sadness, since the bipolar will likely feel they need to get back on top or risk being dominated by others. Even when someone with bipolar disorder experiences temptation or is having fun, they might move to dominate a situation with aggression so they can have what they want or prevent it from being controlled. If they can't have what they want or are prevented from their fun, the person with bipolar disorder can feel as though they might as well die since there is nothing left for which to live.
Thus we see how some of the more serious personality disorders get confused with bipolar disorder. That is, these issues of intensity seem to affect those who have not developed the ability to soothe their own emotions, an ability which can only develop within a consistently loving and safe feeling family atmosphere. A person can have both a serious personality disorder and bipolar disorder since it is so common for bipolar parents to be untreated, and then provide inconsistently loving, dangerous feeling environments for their children. Of course, such children can also inherit bipolar disorder at a genetic level.
When a person with bipolar disorder does not have a personality disorder, the two can be easily differentiated by the bipolar individual's tendency to take responsibility, and the regret they experience after impulsive acting out behavior occurs. These individuals can also be differentiated based on their description of their upbringing. If a person appears to describe a relatively consistent and regular home life from their childhood, but nevertheless exhibits extremely intense emotionality, they are most likely suffering from bipolar disorder as opposed to personality disorder. Overall, such individuals appear to be extremely intense in their reactions, but are also quite empathic and compassionate, which is not found in the more serious personality disorders.
The psychological concept of “repression” is key here. When people are brought up in a relatively trusting and caring environment, they develop a sense of responsibility and depth of caring. Those attributes make a person deny the impulses they experience that are deemed to be threatening to their relationships. Threatening impulses, like aggressive, sexual, or even loving feelings, that would seem to be wrong or damaging to others in some way, are pushed downward and held inside. In the bipolar individual, these feelings become too intense and overcome repression. If the individual does not have a significant personality disorder, the tremendous guilt they experience after these behaviors have been exhibited is clearly palpable and often results in extreme depression. With serious personality disorders, guilt is only fleeting and serious depressions are more centrally located in a deflation of self-esteem, or hating one's self, than in guilt about what's been done.
Repression and intensity are also involved in psychotic disorders. When repression is an especially powerful force, its failure in containing intensity is extremely dramatic, thus causing hallucinations (hearing and/or seeing things that are not there) and/or delusions (strong beliefs about what is happening that defy reasonable judgment), and the psychotic disorder will be thought of as more in the realm of Schizophrenia (a psychotic disorder in which hallucinations, delusions, and/or disorganized confusion occur without significant mood swings). When intensity is the primary issue, but repression fails because it has only developed to normal levels, the psychotic disorder is more in the realm of bipolar disorder. As many will observe, there is great overlap in the medicines used to treat each of these disorders. The overlap between these two disorders is significant because they both involve raw animal emotions filtered through, and morphed by, the desire to protect one's relationships. That is, repression aims to force down feelings, but sometimes those feelings are so powerful that they must be expressed. In order to make them less scary or damaging, repression changes these raw emotions into symbolic beliefs – hallucinations or delusions – that somehow represent the feelings pushing for expression. In psychotic disorders, both repression and intensity are powerful forces. But intensity is primary in the bipolar, while psychosis and the failure of overburdening repression are primary in the Schizophrenic.
It can also be difficult to differentiate impulsiveness related to attention and concentration issues (attention deficit hyperactivity disorder - ADHD) from impulsiveness related to bipolar disorder. Again, one must be able to sense whether the problem is related to intensity, as would be the case with bipolar disorder, or if it is due to a need for stimulation, as is the case in ADHD. Unfortunately, the two overlap, just as they seem to in so many other disorders. People with bipolar disorder are often very sensation seeking because they experience powerful needs. Individuals with ADHD, however, are not filling a void, but rather are just trying to avoid boredom. The best way to tell the difference between the two is in the bipolar's ability to focus very intently on the things that interest them. In those with ADHD it is difficult to focus on anything for much time even if it's fascinating (unless it is also consistently stimulating, like television or video games).
Post-traumatic stress disorder (PTSD) also has significant overlap with bipolar disorder. In the pure case of PTSD a person who has been otherwise quite mentally healthy experiences a traumatic event. That event brings their safety into question and thus stirs up all the most severe emotions related to self-protection. Because those feelings become so intense, people with PTSD can become very aggressive and angry as well as withdrawn and avoidant. The intensity of those feelings becomes overwhelming to someone with PTSD and defies repression, similar to how it does in psychotic disorders. However, because the trauma is very real and the feelings associated are not merely a part of a person's unacceptable self (that is, their rawest emotions), hallucinations and delusions are not a typical part of the picture. That is, the very real emotions of trauma are not thought of as unacceptable aspects of the self because they derive from very real experience that was not within one's control. With PTSD, truly intense feelings are created, but the psychological problem that develops originates in the need to avoid the pain of the experience, which is quite difficult because the memories are extremely powerful and threatening. Avoidance of pain is primary with PTSD as opposed to the expression of intensity as in bipolar disorder.
Even developmental delays involving mental retardation or autism can frequently be mixed with bipolar disorder. Individuals with developmental delays often experience, as part of their disorder, extreme sensitivities or irritability. They frequently become even more susceptible to their own impulses because they do not have the intellectual capacity and/or interpersonal confidence to mitigate the effect of their environment with thought or understanding of their past experiences. Although it is often obvious that the primary issue for such an individual is the developmental delay, the aspect of their disorder that makes them too intense, similar to all the other diagnoses mentioned above, will often be diagnosed as a “dual diagnosis” of bipolar disorder.
Essentially bipolar disorder is a disorder of intensity. Because of that fact, bipolar disorder is often diagnosed within the same person as many other diagnoses. It can also be noticed that the same medications used to treat bipolar disorder are frequently prescribed when the primary diagnosis is in a different area, including personality disorder, schizophrenia, post-traumatic stress disorder, and even in developmental delays. The intensity of bipolar disorder can be likened to that of a reptile that knows only urgent fleeing from predators, fighting for life, and voraciously searching for food. To the bipolar, almost every experience can be interpreted in those terms. Thus, sensitivity to slights, or possible threats, or desires for all sorts of things, often lead to exaggerated intense reactions from the bipolar individual. There is, however, some good news!!! In helping people manage their intensity it can actually be helpful to liken their intensity to the emotional functioning of a reptile, just as described above in discussing the reptilian brain. Once any individual afflicted with inordinate intensity comes to understand that their reactivity is not reasonable or realistic, they can be motivated by their desire to be caring for loved one's to prevent their extreme reactions. They can learn to talk themselves down, excuse themselves from situations before they get too angry, assign friends or family to signal to them when they're showing signs of upset (please see article, Key Signals), take a medicine, or learn to breathe more deeply and rhythmically. Once one knows, and is willing to accept, that they have a hidden reptile inside them, and as soon as they are willing to accept that it can abruptly transform them into a T-Rex with little provocation, in the case of the true bipolar who genuinely cares deeply about loved one's, it is frequently the case that they will do whatever it takes to tame the primitive beast within.