Russ Federman, Ph.D., ABPP
For those living with bipolar disorder, the first few years post-diagnosis can be some of the most difficult in terms of one's relationship to the disorder. Beyond the necessity of initial symptom management, the process of accepting and coming to terms with the reality of one’s bipolar disorder is among the more difficult tasks to be faced.
For most this is a gradual process. Two years post-diagnosis, individuals are usually more accepting than they were on day one. At five years, there's generally a stronger degree of positive adaptation, and so it goes throughout one’s future with the illness; though certainly, there are those whose struggles to find acceptance can be ongoing.
But for those who do strive to live well with bipolar disorder, there are significant challenges that lie beyond issues of acceptance. A salient one involves learning to identify the unique symptom pattern of one’s own illness.
If I were to ask the newly diagnosed person, “what do your bipolar symptoms look like?”, the individual may not yet be fully aware of how his or her symptom pattern presents. Several years into the illness, that same individual will have a much more textured sense of how mood instability is experienced across the mood continuum.
If you look at the American Psychiatric Association's Diagnostic and Statistical Manual 5, you’ll find a broad list of symptoms that typically present during major depression, hypomania, and manic mood episodes. But these aren’t person-specific. Elevated energy doesn’t describe what your elevated energy is like. The same thing applies to symptoms such as racing thoughts, distractibility, increased goal-directed activity, impulsivity, irritability, etc. Only you will be able to identify your unique bipolar symptom set. And just as we see with acceptance of the disorder, individuals with bipolarity do gradually become skilled at recognizing the emergence of their own unique and recurring symptoms over time.
Why is it so important to be able to identify one’s own bipolar symptoms? If the initial signs of symptom onset are noted early enough, individuals are in a better position to take necessary steps towards addressing emerging symptoms that may herald mood destabilization. Once early symptoms progress beyond mild to moderate acuity, it becomes more difficult to be able to return to baseline. If symptoms such as increased energy, strong optimism and lessened need for sleep are early signs of one’s emerging hypomania, then their presence should serve as an alert - a call to action, so to speak, so that one can take steps to mitigate or limit the impact of a mood shift.
A very different reason for improving one’s awareness of mood symptoms involves the importance of distinguishing that which reflects bipolarity vs that which reflects mood and thought processes that are separate and distinct from one’s bipolarity.
For the new traveler across the bipolar landscape, a common response to this last statement may go something like... “you mean, my bipolar illness isn’t the cause of most of my difficulties?” The answer here for many is … probably not. It’s just one of three different threads that combine to make up the fabric of a bipolar life.
Bipolar disorder creates shifts in mood, energy, emotions and thought processes. Sometimes these shifts can occur without any situational precipitants. They just kind of come out of nowhere. In fact, this is one of the key features that differentiates bipolarity from several other disorders. For the BP individual, mood and energetic changes can occur, independent of what’s happening “on the outside.” And with regard to the inside (the mind), bipolar-related changes in emotion or thinking can still be occurring independent or separate from that which is consciously intended or wanted. Thus, we see that bipolar illness reflects problems with the brain’s ability to maintain continuous stable mood. This is the first, and the most essential, of the three threads associated with bipolarity.
A second thread involves the strong influence of personality, which is an area I perceive as receiving inadequate attention throughout much of the bipolar literature.
Think of the broad range of individuals that don’t necessarily carry a psychiatric diagnosis. For some, their mood can remain fairly stable over time. Somehow, they have the gift of being able to maintain calm and stable mood. They don’t struggle with strong emotions that create uncomfortable mood intensity. I suppose most would view this as desirable, unless of course, you’re someone who perceives quality of life as entailing a high degree of mood intensity.
But I think we’d also agree that there are a fair amount of people who do live with strong mood intensity, much of which is not necessarily felt as “desirable.” People are angry, irritable, needy, gloomy, anxious, worried, driven to achieve, preoccupied with physical appearance, strongly emotive, impulsive, etc. At least as pertains to Western culture, our population is not an aggregate of people that live with a high degree of peace and contentment. My point here is that personality or the aggregate of one’s psychological processes is complex, often intense and ubiquitous in its impact upon “how we are” in the world.
Indeed, personality has an integral role in its contribution to an individual’s evolving mood states. And, there’s some really good news here. While we don’t have a cure for bipolarity, basic aspects of personality are changeable over time, particularly for those with strong motivation towards change. In fact, personality can and often does change and evolve as a function of maturation, which can continue across the entirety of one’s life cycle. But beyond maturation, substantive shifts in “how we are” can occur through strong commitment to self-awareness, personal growth and even psychotherapy. We’re not just stuck with our enduring patterns. We all represent “works in progress.”
And the third thread? It’s actually the most obvious. It’s the environment.
Those who live with bipolarity have a low reactivity threshold in relation to the impact of environment upon mood stability. Below are three examples with altered names of patients I’m currently seeing, all of whom live with the bipolar diagnosis.
- 20-year-old Gwen finds that she continues to rapid cycle between mild to moderate mood elevation and depression. It’s the 13th week of a 16-week semester and she’s getting inadequate sleep as a result of writing papers, studying for finals, rehearsing for a theatrical production and being chair of her sorority rush class.
- 38-year-old Linda is also rapid cycling. She’s raising three children, works as a nurse, gets inconsistent sleep, and has very limited emotional support from her husband.
- 31-year-old Jonathan has recently relocated to accept a position for post-doctoral chemical research fellowship. He’s been moderately depressed for about a half-year. He has glimpses of respite from his low mood but the combination of high work-related productivity expectations and the emotional isolation of being a 30-something single male, continue to cause him to relapse into his depressive funk.
All three of these individuals are faced with situational factors that would be challenging for anyone. The fact that they each live with bipolarity (two with BP I and one with BP II) means that their mood symptoms are situationally exacerbated and their return to balanced mood is a further stretch than it would be for most without the bipolar diagnosis.
To summarize, at any given point in time, individuals living with bipolarity may be affected by:
1.) Endogenous neurochemical changes
2.) Exacerbations of mood and emotion brought on by the role of personality
3.) Strong degrees of stress upon the mind and body as a function of the surrounding environment.
Now, it’s important to recognize that we rarely get to observe experience that’s sufficiently unidimensional as to reflect the isolated factors as identified in the previous paragraph. Indeed, those different threads are synergistically interacting much of the time. They don’t exist in isolation and the broader picture, reflecting their interactive outcome, is what those with bipolarity are dealing with much of the time.
So, what's the point? Why conceptually delineate things that don't have impact in isolation from other factors?
The answer is that through better understanding of the separate components of experience, one can gradually become more skilled at disentangling the threads that comprise the fabric of a bipolar life.
Russ Federman, Ph.D., ABPP is a psychologist in private practice in Charlottesville Virginia, specializing in psychotherapy with individuals having bipolar disorder. Dr. Federman writes an ongoing blog for Psychology Today titled “Bipolar You.” He is a contributor to IBPF’s on-line book – Healthy Living with Bipolar Disorder. He is also co-author of the book – Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger, 2010).