Bipolar - and its multiple meanings

The term bipolar has multiple meanings in psychology, and is often misused or misunderstood in colloquial use of the term. Many people use the term "bipolar" colloquial to refer to impulsivity or moodiness, which are more often traits of borderline personality organizations or borderline personality disorder. While impulsivity is frequently a symptom of mania - one polarity of bipolar disorder - it is not at the core of the illness.

So what is bipolar disorder? There are several things to cover: bipolar disorder as we currently understand it, hypomanic personality disorder as it is currently understood to differ from bipolar disorder, and unrelated bipolarity in personality. Historically, bipolar disorder was referred to as manic-depression. Bipolar disorder can occur without depression, solely manic episodes, according to DSM diagnostic criteria. Mania is a period of time in which we need little or no sleep, have increased energy despite lack of sleep, often grandiosity and flight if ideas, pressured speech and gregariousness, euphoric mood, and impulsivity such as overspending or reckless behaviors like speeding, risky sexual behavior or substance use. It often occurs with markedly diminished (or non-existent) insight (the person is unaware of the illness or that the behaviors are unusual or concerning, in fact if they recognize the change, they are often happy about it).

Clinical notes: Bipolar disorder can be florid, and easily recognizable or can take years to confidently diagnose.

• Does the client have periods in which they need markedly less sleep (ie., normally gets 8-hours, but feels fine after 5 for days on end) or no sleep without feeling fatigued for several days?

• Comparing symptom presentation between individuals with bipolar disorder and major depressive disorder, people with bipolar disorder are significantly more likely to experience both hypersomnia and insomnia than people with unipolar depression.

• While not compatible with the diagnostic criteria in the DSM, in reality many people with prolonged periods of untreated bipolar disorder may have ultra-rapid cycling or ultradian rhythms, which can be difficult to distinguish from mood swings in cluster c personality types.

• Assessing mood episodes: many clients with bipolar disorder are poor historians due to insight / memory symptoms, but ask them to go backwards in time reflecting on mood changes / episodes. Create a timeline of depression, euthymia and possibly mania / hypomania. Clients often become more confident historians and you and the client may be able to identify discrete manic or hypomanic periods from simply feeling good, as well as noting seasonal patterns that help with coping-ahead, or making lifestyle change adjustments ahead of time to lessen symptoms.

We currently conceptualize bipolar disorder as a medical disorder with an underlying biological process. Specifically, as a circadian rhythms disorder. My former supervisor, Dr. Ellen Frank, referenced the old Timex or Casio watch commercials in which it is dropped from a building and keeps ticking, but a Rolex would break. The average, well-person would be the Timex, with a sturdy, durable internal clock, or circadian rhythms, but the bipolar internal clock was a fragile one that needed extra care. Changes in daylight or traveling across time-zones could be a major trigger. Medications often effectively treated the positive symptoms (mania) but left people sluggish, zombified, and depressed - negative symptoms remained. Dr. Frank added the social rhythm component to Intpersonal Psychotherapy (IPT), coining Intperpersonal Social Rhythm Therapy (IPSRT). This was quite helpful for people to manage their circadian rhythms, reduce medication reliance and improve symptoms of bipolar disorder. My experience has been that many people are pre-contemplative or contemplative about these lifestyle changes, namely getting up and going to bed in a consistent (+/- 15-30 minute) window every day, but those who engage in the interventions see notable outcomes.

Historically, defense mechanism language was used to conceptualize manic episodes. The defense mechanism is denial of depression and is the characteristic coping strategy of those with hypomanic personality disorder (Psychodynamic Diagnostic Manual - PDM). A defense mechanism is designed to protect our ego from conscious awareness of things that could cause insult. Depression, and our self-perception in a depressive state, would certainly be a wound. Consequently, there are functional benefits to denying depression, but mania results in overshooting into grandiosity. Hypomanic personality also involves a certain flittiness (and fear of interpersonal closeness), even so far as moving out of town abruptly, which may sound akin to a fugue state, but without the departure from a part of the self: it is a horizontal rather than vertical split in personality.

A horizontal split involves a repression barrier (often, more specifically, denial) in which an experience is pushed or kept out of consciousness - below the water in the iceberg analogy of Freud's model. A vertical split is a separation of parts of ourselves, or states of mind, that may have varying degrees of awareness of each other (or other states of mind). A depressed person intellectually knows that a healthy mindset exists, that they have come out of depression in the past, but emotionally it feels like a complete truth that life is hopeless and they will never return to health - this is a vertical split.

The traditional psychoanalytic conceptualization of narcissism is comparable to that of hypomanic personality: a grandiose conscious experience is horizontally split from a repressed depressive experience, kept out of conscious awareness to whatever degree is possible. However, Kohut posits that there are both horizontal and vertical splits in narcissistic personality. A subtler, more acceptable and more formed depressed state is split vertically from grandiosity, but below it is a more fragmented, horizontally split depressive state. We could think of this analogously to the Interpersonal Psychology notion of me (grandiosity), bad me (vertically split depression) and not me (horizontally split depression). The latter are things we put a lot of unconscious psychological energy in keeping at bay and at times projecting outwards onto others, both of which with interpersonal sequelae: pulling others to acknowledge our greatness, enmeshing with idealized others, projecting "not me" onto others and devaluing them.