For many, living with mental illness can be an overwhelming and isolating experience. Bipolar disorders are a serious and persistent form of mental illness that affects millions around the world - but these illnesses don’t have to define you or your life. Whether you live with or know someone living with a Bipolar Disorder, it is important to understand the dynamics involved in Bipolar I (BDI), Bipolar II (BDII) and Cyclothymia. This post will explore the characteristics of each type of disorder, how symptoms may differ within each, and psychodynamic therapy as a means to promote well-being for those affected by these conditions.
Types of Bipolar Disorders: Bipolar 1, Bipolar 2, and Cyclothymia
Mental health awareness has grown significantly over the years, and with that comes recognition of different types of illnesses and acknowledgment of the toll taken on those affected. One such illness is Bipolar Disorder, which consists of three different subtypes: Bipolar I, Bipolar II, and Cyclothymia. Notably, the Bipolar Disorders are among the mental health conditions with the strongest genetic loading. Those with an immediate relative have a 10-fold risk in developing a Bipolar Disorder relative to the rest of the population.
Bipolar I is characterized by the presence of at least one full manic episode. Contrary to popular belief, a period of depression is not required to meet criteria for Bipolar I, though depression may precede or follow mania. A manic episode refers to marked changes in mood and behavior for a discrete period of time.
During mania, an individual experiences abnormally and persistently elevated and expansive mood, feeling as if they are “on top of the world.” For others, the mood change represents a shift into significant irritability. This change represents a qualitative, noticeable difference from the individual’s normal mood. To be considered a manic episode, the shift to buoyant or irritable mood must continue for a full week and be present for most of the day, nearly every day. However, if during the course of the manic episode the individual is hospitalized either for their safety or the safety of others, they are considered to have been in the midst of a manic episode regardless of its duration.
Mood is not all that changes during mania. We would need to see at least three or more of the following deviations from the person’s normal behavior (or four if one’s mood is irritable rather than inflated). These changes include a sudden decreased need for sleep: those affected will often feel well-rested after only 2-3 hours of sleep at night. Indeed, this sense of heightened energy following a paradoxical drop in sleep can be a harbinger to a manic episode. Other features that might indicate mania include an inflated sense of self-esteem or grandiosity or becoming excessively talkative or having pressured speech. The pressured nature to one’s speech is often rooted in one’s sense of having a flight of ideas or racing thoughts. Manic episodes may include heightened distractibility (distinct from ADHD in that challenges in sustaining attention are not linked with inflated mood, self-esteem, or risk taking). The individual may engage in what is called “goal-directed activity,” that is, expending inordinate focus, effort, and resources to obtain a particular end. Examples could include suddenly spending all day and night working on an opera, writing a complicated manuscript, or creating plans for a far-fetched business venture.
This may overlap with another feature of mania: engaging in activities that have a high potential for painful consequences. Examples could include foolish business investments with one’s life savings, sexual indiscretions without regard for the health or interpersonal consequences, buying sprees, or risky driving without apparent concern for the consequences–all of which would be outside the norm for the individual.
The excessively cheerful, high, on-top-the-world feeling during a manic episode might have an infectious quality easily recognized as excessive. Those around the affected individual should be able to sense this seemingly unlimited, haphazard enthusiasm for interacting with others. Long-winded conversations with strangers are struck up, and speech may be rapid, loud, and difficult to interrupt. The affected individual may speak continuously and theatrically, virtually without concern for the actual content of the message. In the event that the person’s mood is irritable rather than buoyant, this stream of speech is more likely to contain hostilities, tirades, or complaints.
When in the midst of a manic episode, the individual tends to not recognize that they are experiencing a Bipolar disorder, and suggestions that they enter treatment are often resisted energetically. We may see changes in self-presentation: one’s dress, makeup, or style tends to become more flamboyant or sexually suggestive. Other individuals may become hostile or threatening to others. Because of the poor judgment, lack of insight, and impulsivity that can emerge during mania, the individual may experience highly undesirable consequences, such as financial hardship, the loss of important relationships, legal difficulties, or involuntary hospitalization.
A single episode of mania in the course of one’s lifetime is sufficient for a diagnosis of Bipolar I disorder. However, a depressive episode may precede or follow the manic episode. While a manic episode lasts for at least one week, a depressive episode has a different criterion: it must last nearly every day for at least two weeks. In contrast to the inflated mood, grandiosity, energy, and reckless enthusiasm of mania, the hallmark of depression is significantly lower than normal mood or the inability to experience or expect to experience pleasure.
During depression, we would also expect to see some combination of the following: insomnia or excessive time spent sleeping, significant and unexpected weight gain or weight loss, or marked increase or decrease in appetite. Others might notice changes in their movement, so pronounced that others around them notice shakiness in their hands and feet, or–on the opposite end of the spectrum–a slowness in one’s movements. Fatigue is common, as are impairments in the ability to concentrate or think clearly. Depression can bring feelings of worthlessness and inappropriate guilt. Finally, we may see recurrent thoughts of death, thoughts of ending one’s life without a concrete plan, the formation of plan to end one’s life, or even a suicide attempt.
While Bipolar I is considered to be present with a manic episode alone, Bipolar II is different: the affected individual must have had a current or past depressive episode.
In addition to this, a hypomanic episode must have taken place. As “hypo” denotes “beneath,” a hypomanic episode lasts at least 4 days (rather than a full week or more in a manic episode). In addition, the hypomanic episode is not necessarily severe enough to require that the individual be hospitalized; it may not even cause impairment in one’s job or social life.
While there remain important distinctions between the length of time and severity of manic and hypomanic episodes, Bipolar II is not considered a “milder form” of Bipolar I. This is due to both greater duration of illness and longer time overall spent in depressive episodes among those with Bipolar II. The impact of depression can be severe, and even disabling.
It is most common that those with Bipolar II reach out to a healthcare professional during a depressive episode. They likely will not register their time in a hypomanic state as problematic, as these periods in and of themselves tend to not lead to demonstrable harm. Rather, the felt disruption feels rooted in the persistent bouts of depression, the pattern of significant and unpredictable mood change, and challenges in social and work life because of this.
When we see long-standing, fluctuating mood disturbance including periods with hypomanic features–and at other times, periods of depressive symptoms–one is likely experiencing Cyclothymic Disorder. In this case, one’s depressive symptoms would not meet the number, severity, or duration to be considered a full depressive episode. Similarly, the individual’s hypomanic symptoms would not meet the requisite number, intensity, or duration to be seen as a full hypomanic episode. This oscillation between mood states would be seen for 2 years. To be considered Cyclothymic, one’s symptoms would be present more days than not. In addition, any time free of mood symptoms would last no longer than 2 months. Finally, there is significant likelihood that a person experiencing Cyclothymia will later develop a Bipolar I or Bipolar II disorder.
Living with Bipolar Disorders
The impact of Bipolar Disorders is significant, and emerges from both ends of the mood spectrum. During mania, risking one’s life savings on a shaky business venture or investment can court financial ruin. Unprotected sex with a string of strangers can open the door to HIV or other serious infections, or risk loss of important relationships. Shopping sprees during manic episodes have left people unable to buy groceries for their family or pay rent. Significant legal problems can result from the risk taking without regard for the consequences.
Depression can take a toll on one’s physical health, relationships, and ability to work as the individual loses energy, motivation, and satisfaction from their relationships or pursuits. The risk of dying by suicide is 15 times higher among those with Bipolar I than in the general population.
While most people with Bipolar Disorder will reach a fully functional level between bouts of mania and depression, a significant portion of people continue to have significant difficulty in fulfilling the duties of their work. Recovery can lag behind relief from one’s symptoms, such that even when one is not “diagnosable,” the challenges of living with Bipolar Disorders can still be felt. Other individuals will transition directly from a manic episode into a state of depression without any time to stabilize and recover.
For those living with Bipolar II Disorder, the most significant distress often results from the depressive episodes, or from the disruptions in social life or at work that stem from unpredictable mood changes. Isolation, loneliness, and strife can result if one is seen as temperamental, inconsistent, or unreliable.
A significant challenge associated with the treatment of bipolar disorder occurs in the midst of depressive episodes: some individuals report that the significantly low mood, lack of energy, and loss of pleasures leaves them dreaming of the peak of the manic rush. Thus, they stop taking their mood stabilizer without consulting their doctor in order to invite a new manic episode. This is dangerous, and ill-advised.
Another challenge comes with the side effects of lithium, a medication commonly used to treat Bipolar Disorders. Some individuals experience muscular tremors, an experience some find aversive or embarrassing. This can lead some to quit taking their medication, which unfortunately leaves them prone to further manic episodes. Those who do stay on lithium must be regularly monitored by their prescribing physician for lithium toxicity, a dangerous and potentially fatal condition. It is vital to follow your doctor’s orders, and discuss any desire to stop taking your medications with a medical professional.
With a combination of therapy and medication, life with a Bipolar Disorder does not have to be a struggle. Mania and depression are both impacted by proper treatment, and a more stable emotional and social life is attainable.
Psychodynamic Treatment for Bipolar
Psychodynamic Therapy is an umbrella term for treatments that focus on the underlying–often unconscious–aspects of our being that impact how we feel, behave, and relate to the world around us. As long as these patterned ways of being remain underground and outside of awareness, they can feel like inevitable forces in our lives. Often, a psychodynamic therapist will use the therapeutic relationship as a means to sound out the parts of ourselves that are hidden from awareness. In the context of a safe, empathic environment, you are invited to explore the parts of yourself that are kept hidden–sometimes unintentionally so. The more awareness we can bring to the less known parts of ourselves, and the more room we can make for them. We become less likely to be mindlessly driven or caught by the invisible patterns of our lives.
Bipolar disorders are best treated with a combination of medication and psychotherapy. Medication is generally used to target manic episodes, and therapy for depression. However, a psychodynamic approach can be useful in making space to process the entirety of one’s experience living with a Bipolar Disorder. One can come to understand the interpersonal patterns that provoke and sustain distress, and also explore the unique meaning of the relationship they have with their experience. For example, per mania: is it secretly hoped for? Reviled? What purpose does it serve, if any? How am I impacted by others’ views of me that change how I feel about and treat myself? These are questions that medication–though vitally important–cannot answer, and lead to material changes in the lives of those fighting to find peace in the midst of an emotional storm.
Exploring the roots of our emotional experience in psychodynamic therapy can lead to significant improvements in mood and overall psychological well-being. This is a compassionate approach to navigating turbulent moods, helping individuals improve their relationships, working through past traumas, and ultimately achieving a greater sense of balance and peace.
Living with a Bipolar Disorder or any mental illness can be a difficult journey. With proper treatment, understanding, and support, we can work together towards improving the quality of life for those affected. If you are fighting your battle with a Bipolar Disorder or wonder whether you may have one, reach out for help by scheduling a free consultation with us for therapy or assessment. At Relational Psych, we are here for you on the road to healing.