Bipolar Disorder
                              

                                               by Dr. Daniel A. 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 ones
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 ones 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 ones 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 ones, it is frequently the case that they
will do whatever it takes to tame the primitive beast within.