001

Table of Contents
 
Title Page
Copyright Page
Dedication
PREFACE
Introduction
Acknowledgements
 
Part 1 - Understanding Bipolar Disorder
 
CHAPTER 1 - What Is (and Isn’t) Bipolar Disorder?
 
BIPOLAR DISORDERS
GOING TO EXTREMES: BIPOLAR BEHAVIORS
PSYCHOTIC SYMPTOMS
 
CHAPTER 2 - A Brief, Colorful History (and Some Science) of Bipolar Disorder
 
FROM MANIA AND MELANCHOLIA TO BIPOLAR DISORDER
THE BIOLOGY OF BIPOLAR DISORDER
PROMISE FOR THE FUTURE
 
CHAPTER 3 - Getting an Accurate Diagnosis
 
BIPOLAR DISORDER CAN BE DIFFICULT TO DIAGNOSE
DUAL DIAGNOSES: COEXISTING PSYCHIATRIC DISORDERS
COEXISTING MEDICAL DISORDERS
WHERE TO GET THE BEST DIAGNOSIS
FINDING A PSYCHIATRIST
HEALTH INSURANCE
 
CHAPTER 4 - Understanding Medication
 
COMMONLY PRESCRIBED MEDICATIONS FOR BIPOLAR DISORDER
NONCOMPLIANCE
CHANGING MEDICATION
TAKING MEDICATION SAFELY
 
CHAPTER 5 - Understanding Psychosocial Therapies and Medical Treatment Options
 
PSYCHOSOCIAL THERAPY OPTIONS
CHOOSING A QUALIFIED (NONPSYCHIATRIST) MENTAL HEALTH PROFESSIONAL
OCCUPATIONAL AND REHABILITATION THERAPIES
OTHER MEDICAL TREATMENT OPTIONS
 
Part 2 - Living with Your Partner
CHAPTER 6 - Building a Support Team
 
WHOM SHOULD YOU TELL?
TELLING YOUR CHILDREN
TELLING PARENTS
TELLING OTHER FAMILY MEMBERS
TELLING FRIENDS
TELLING NEIGHBORS
TELLING EMPLOYERS
GROUPS
 
CHAPTER 7 - Bipolar Disorders and the Workplace
 
TO TELL OR NOT TO TELL
TALKING TO THE BOSS
DECIDING WHETHER TO TELL COWORKERS
HELPING YOUR BIPOLAR PARTNER APPLY FOR WORK
HOW THE AMERICANS WITH DISABILITIES ACT (ADA) AFFECTS PEOPLE WITH BIPOLAR DISORDER
YOUR PARTNER MAY QUALIFY FOR SOCIAL SECURITY DISABILITY INSURANCE (SSDI)
 
CHAPTER 8 - Communication and Coping Skills
 
STRATEGIZE AND SET LIMITS AHEAD OF TIME
EFFECTIVE COMMUNICATION STRATEGIES
SUPPORTIVE STRATEGIES
COPING WITH MANIA
COPING WITH DEPRESSION
 
CHAPTER 9 - Coping with Negative and Dangerous Behaviors
 
NEGATIVE BEHAVIORS
DANGEROUS AND DESTRUCTIVE BEHAVIOR
HEADING OFF NEGATIVE AND DANGEROUS BEHAVIOR BEFORE IT GETS OUT OF CONTROL
 
CHAPTER 10 - Sex, Intimacy, and Relationship Issues
 
HYPERSEXUALITY
LACK OF INTEREST IN SEX OR INTIMACY
WORKING ON YOUR RELATIONSHIP
RECIPES FOR SUCCESS
 
CHAPTER 11 - Suicide Attempts, Hospitalization, and Commitment
 
PAYING ATTENTION TO SUICIDAL THOUGHTS OR BEHAVIOR
HOSPITALIZATION
IF YOUR PARTNER NEEDS TO BE COMMITTED
 
CHAPTER 12 - Family Matters
 
HEALTHY FAMILY GUIDELINES
WHEN YOUR PARTNER IS NOT THE ONLY ONE IN THE FAMILY WHO IS BIPOLAR
WHEN YOU HAVE A BIPOLAR CHILD
WHEN YOU HAVE PROBLEMS OF YOUR OWN
WHEN BOTH OF YOU ARE BIPOLAR
WHY DID YOU END UP WITH A BIPOLAR PARTNER?
APPENDIX - Excerpts from the DSM-IV-TR Diagnostic Criteria for Bipolar Disorder
NOTES
RESOURCES
ABOUT THE AUTHORS
INDEX

001

To our agent, Gina Panettieri—you rock!—and to my six parental units
—Chelsea Lowe
 
To my mom and dad, who both in their own ways spent their lives caring for others
—Bruce M. Cohen

002
PREFACE
My very first psychiatric patient had a form of bipolar disorder. She was a brilliant young woman whose illness had disrupted her life, her career, and her relationships. Fortunately, her symptoms first waned and then vanished in the face of comprehensive treatment. Her astonishing experiences—of mood swings and delusions followed by sanity, of wild behaviors and speech that resolved to reveal a wise and thoughtful wife and mother—convinced me that I wanted to spend my career trying to understand and improve care for people with this fascinating condition.
For more than thirty years, I have specialized in the psychiatric treatment of patients with bipolar disorder. I have helped care for thousands of patients, and run a major hospital dedicated to those with psychiatric disorders. As a researcher, I have sought and still actively seek to develop new and better treatments. I have written many articles and chapters, both on my own work and to guide others studying and treating bipolar disorder. Along with many others in my field, I have kept looking for better ways to help.
Early in my career, I recognized the importance of including partners and relatives of the patient in my own care of those with psychiatric illnesses. Often my patients brought their partners to appointments; sometimes they were brought by their partners. I soon learned that things almost always went better when a partner was involved: I got more information; my patient got more help and support. After all, patients don’t just need doctors. Yes, they need a thorough personal evaluation, followed by professional monitoring and treatment; but they also need a well-organized life. All these needs are best addressed with the involvement of people who care enough to learn about the illness and be part of the overall plan of treatment.
When Chelsea Lowe asked me to contribute to this book—written to address the needs of the partners of people living with bipolar disease—I thought she had a wonderful idea, and I was glad to help. As I spoke to patients and their partners, relatives, and friends, I had come to see the effects of bipolar disorder on them all. I realized that partners wanted to be involved and supportive, but didn’t know how. They needed to know what was happening, what would make things better, what was dangerous and might make things worse, what roles they could play. Because they were affected, they needed to know; because they cared, they wanted to help.
Most people, however, know little about psychiatric disorders, and much of what is portrayed in movies or books serves a dramatic point and may not be accurate. There are many factual books, good ones, from brief to encyclopedic, on bipolar disorder. Some of these are listed in the Resources section at the end of this book. Mostly, these books were written by doctors or patients and for doctors or patients. Few, if any, were written for the partner of someone with bipolar disorder. Although much of what we each need to know is the same, not everything is. Partners have different experiences, a different role, and different needs than doctors or patients.
This book is written specifically for partners of people who suffer from bipolar disorder. We know from our own experiences that accurate information and good advice on bipolar disorder can lead to better relationships and more productive lives. We hope the information in this book will provide you with a solid foundation of understanding and will give you and your loved one useful guidance and assist you in understanding your options and accessing the resources you need.
 
Bruce M. Cohen

003
INTRODUCTION
Bipolar disorder, or BD, is common—many millions of people around the world have it, and millions more are diagnosed with it each year. We know from surveys that a great many people suffering from bipolar disorder go undiagnosed. Most of us, whether we realize it or not, know someone who is living with bipolar disorder—a colleague, a roommate, a friend. And many people live with someone who is living with BD—a partner, a parent, a child. Being part of the life of a bipolar person can be difficult, confusing, and frustrating. If we don’t understand the disorder and how it affects our loved one, our relationships can easily spin out of control.
The symptoms of bipolar disorders—plural, because BD has many forms—can range from the wild behavioral extremes of mania (outrageous confidence, spending or gambling away fortunes, embarking on ill-conceived affairs, quitting steady work to pursue an irrational dream) to the quieter but equally troubling consequences of severe depression (immobilizing fatigue, deep sadness, overwhelming self-doubt, and loss of pleasure).
Often, partners and family members are surprised to discover that the person they’ve known for so long is in fact bipolar, not just difficult or moody. Cavernous depressions, irrational irritability, insistent speech that denies would-be conversational partners the chance to participate, disorderly thinking, poor judgment, resistance to help, and other symptoms can be trying for those close to an individual with bipolar disorder. More often than not, they have a difficult time finding a reliable source for information and support.
Yet for those whose lives are affected by bipolar disorder, these are good times to live in. Never before have people with BD enjoyed better access to adequate diagnoses, medications, and support. Never has awareness of the condition been greater. And for most individuals diagnosed with one of the various types of bipolar disorder, there is at least one other—a spouse, parent, child, sibling, or friend—who cares, wants to help, and desires, for themselves and their loved ones, to enjoy a fulfilling life and good relationships.
To this end, information—about bipolar disorder, about how it affects our loved ones—is vital: the more we have, the less we avoid, patronize, or stigmatize the person with BD, and the better able we are to deal, singly and together, with the problems that are bound to arise. People living with people who are living with BD need information and understanding, help and support, every day. That’s why we wrote this book.
Living with Someone Who’s Living with Bipolar Disorder is organized into two parts. The chapters in Part One, Understanding Bipolar Disorder, address the nature of this illness, a bit of its history, and the medication and treatment options available to those living with BD. The chapters in Part Two, Living with Your Partner, speak to the needs of the relationship and two people in it, particularly the partner—named in the title of this book—who is living with someone living with bipolar disorder.

ACKNOWLEDGMENTS
Writing a book is hard. Writing one with an actively involved coauthor is doubly so. I was truly fortunate to have been matched with Dr. Bruce M. Cohen, who immediately put the lie to any clichés about doctors and ego. I’m grateful for his kindness, patience, dedication to the work, and refusal to allow his name to appear before mine in the credits.
Adriana Bobinchock made my job infinitely easier, as she so often has. Gina Panettieri can’t really be thanked enough. The same is true of Sallie Randolph, who showed extraordinary goodness in coming to my assistance.
Peter Pearson, PhD, director of the Couples Institute in Menlo Park, California, and Brian Quinn, LCSW, PhD, astonished me with their generosity of time and expertise. Drs. Jacqueline Olds, MD, and Tina B. Tessina, PhD, were similarly gracious, as were Dost Onger, MD, PhD, and Dr. Stephen J. Seiner, MD. Thanks also to the Social Security Administration, the office of the Equal Employment Opportunity Commission, NASA’s Johnson Space Center, and the Federal Aviation Administration for putting up with my ignorance kindly and patiently. The City of Boston Women’s Commission, the Massachusetts Department of Public Health, the Samaritans, the Depression and Bipolar Support Alliance, and the Academy of Cognitive Therapy were generous and kind as well.
Thanks also to the U.S. Substance Abuse Mental-Health System Administration and to Skenderian Apothecary, Cambridge, Massachusetts; Boston College; Karen Sontag; W. Thomas Smith Jr.; and Dr. Judith Beck.
Russell Wild, MBA, and Joel Schonfeld, JD, helped me understand the wherefores of lenders.
My gratitude goes, as always, to the American Society of Journalists and Authors, my sine qua non, and to Catherine Wald, Patti McCracken, Erica Manfred, Nancy Peske, Stephanie Golden, and Alexandra Owens.
Thanks as well to Sergeant Jim Bailey, Drs. Jon and Jill Ladd, and Dr. Carolyn Maltas. And to my husband, as always, for his insight, support, advice, and killer sense of humor.
Thanks, most of all, to the men and women who shared their stories.
 
—Chelsea Lowe
 
I gratefully acknowledge:
Chelsea Lowe, for the idea and drive to write this book, for laying out all its initial content, for many hours of redrafting, and for asking me to join her in this work; Naomi Lucks, for reading the drafts comprehensively, asking good questions, making sure that all that needed to be said was said, and for expert and exceptional help in organizing and editing; Alan Rinzler, for appreciating the value of this project and shepherding it through to conclusion; my clinical colleagues Philip Levendusky, PhD, Dost Ongur, MD, PhD, Paul Barreira, MD, and Jean Frazier, MD, for input on technical aspects of bipolar disorder, its treatment, and resources to help patients and families; my colleagues at the Frazier Institute, Sue Babb, MS, and Cathie Bowen, for help with searches for information and with text preparation; Adriana Bobinchock, the head of McLean Public Relations, for help with contacts and for reading our drafts and advising on content; and my wife, Marian Cohen, PhD, professor of sociology, Framingham State College, for many insightful discussions on dealing with psychiatric disorders and other sources of stress and misbehavior in life.
—Bruce M. Cohen

Part 1
004
Understanding Bipolar Disorder
005

006
CHAPTER 1
What Is (and Isn’t) Bipolar Disorder?
Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide.
 
I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do.
—Kay Redfield Jamison, PhD
 
 
Kay Redfield Jamison, who writes eloquently about her experience with bipolar disorder, credits others with helping sustain her. She knows very well that bipolar disorder doesn’t affect only one person and is best managed by two or more people working together. Let’s listen to the voices of people who are living with people with bipolar disorder:
My husband, Ryan, is manic-depressive, although I didn’t know that when we got married. I thought he was just moody, and—I can’t believe this—I thought it was kind of attractive; he was unpredictable and mysterious, like a romantic poet. But the poetry became work. And that’s not even his depression phase—that’s his manic mood! A lot of people think the manic side is happy. But his shrink told me that mania doesn’t always look “happy, happy, happy.” More often than not, it’s irritability that explodes into rage. Great, right?
—Jane Pastalouchi, Des Moines
 
When my ex-girlfriend told me she was manic, I said, “No, you’re totally out of control.” And she was! In the summer especially, she could never sleep. So she’d spend hours rollerblading—in the dark! Then I couldn’t sleep because I was worried she’d fall and break something, or be attacked by someone less innocently out at night.
—Harold Goldstein, New York City
 
Jeff was hilarious—a really great guy to be around. He was so funny and so handsome—when we got dressed for a party, he was almost shiny, like a celebrity. He was kind of famous, actually—a pretty well-known photographer, and his output was phenomenal. But then, over the course of a week or so, he’d spiral down. The bottom would just drop out. He’d get so low he was unrecognizable, almost. He stopped working, shaving, bathing, even talking . . . he wouldn’t change his clothes. He looked like a homeless person. Our kids thought it was like having two dads, and pretended it was funny, but it wasn’t. Now, when my teenage grandson goes radio silent and shuts himself in his room, I wonder if it’s happening all over again . . .
—Helen Watchover, Los Angeles
My wife seemed fine. She was great with our kids—lunches, school, homework. And I really depended on her to do that. Didn’t think twice about it. When she was stressed, she’d cry a lot, but then she’d snap out of it, and she seemed really happy again—baking cookies, cleaning the house from top to bottom, cutting out a million coupons—the whole Mom thing. She went to therapy, sure, but who doesn’t? Then one night before dinner she told me she wanted to die. She had it all planned out. I got really scared and called her therapist, he had her come in, and the next thing I knew she was hospitalized. Now she’s on some kind of medication, and she seems pretty even, but sometimes I get scared that she’ll stop taking it and want to kill herself again.
—Michael Jetter, St. Louis
Does any of this sound familiar?
If your partner or loved one is bipolar, you have your own stories to tell. You may be lucky enough to have found someone who’ll listen, or you may feel too embarrassed and just hope the problem will go away. This suppression can make you feel isolated and alone. But although you may often feel isolated, you—and your partner—are far from alone.
Bipolar disorder—or more accurately disorders, as there are multiple types—is an often misunderstood and misdiagnosed group of illnesses believed, conservatively, to affect more than five million American adults. The National Alliance on Mental Illness, considering all of the bipolar and related disorders, puts the figure closer to ten million.
To give you some perspective on this number, approximately 2.2 million people over eighteen in the United States are thought to suffer from obsessive-compulsive disorder; 2.4 million from schizophrenia, 4.5 million from Alzheimer’s disease; and about 18 million from diabetes. So yes, by any standard, there are a lot of people living with bipolar illness, and many more who are living with these folks.
What is bipolar disorder? Well, first, its name comes from its most obvious characteristic: people with bipolar disorder tend to experience extreme, polar opposite states of mood. They can be exceptionally high, or “manic,” at one time, then exceptionally low, or “depressed,” at other times. Although there is much more to BD, as you will see, the extreme moods are what people note most often.
As to cause, bipolar disorder is not your partner’s “fault”: it is a brain condition. It does not happen because of upbringing, although it can be triggered or worsened by physical or emotional trauma or extreme stress. (The same is true of many medical conditions, such as high blood pressure.) It does not happen because your partner wants it to, either.
Although it may not be chronic (meaning symptoms never go away), it is usually recurrent (that is, symptoms keep returning), and some symptoms can linger, even when someone with bipolar is not having a full episode of illness. To varying degrees, these symptoms and episodes can be managed. The most common treatments are medication, neuro-therapies (physical treatments, other than drugs, to change brain activity), and supportive therapies (such as psychotherapy). We’ll discuss all of these in greater detail later in this book.
In this chapter, however, we’ll address the basic question: What does bipolar disorder look and feel like?

BIPOLAR DISORDERS

Bipolar disorder is characterized by its episodes of extremes in mood, and that’s what people with BD actually experience. Understanding the nature of these moods makes it easier to understand the differences between the types of bipolar disorders.

Bipolar Moods

A manic episode is typified by elevated mood, increased energy, and perhaps paradoxically, irritability. Often there is a sense of power or importance, rapid thinking, talkativeness, a flurry of activity, and decreased need for sleep. There may be impaired thinking and psychotic symptoms (delusions and hallucinations). In a manic episode, symptoms are severe enough to cause substantial disruption to daily life and obligations. Sometimes hospitalization is required.
A hypomanic episode has the same basic features as a manic episode, only milder. By definition, hypomanic symptoms do not cause severe disability or hospitalization and are not associated with psychosis.
A depressive episode is characterized by sadness or low mood; diminished energy, interest, and pleasure; greater or lesser appetite for food; excessive or poor-quality sleep; and feelings of worthlessness or guilt, and even despair.
Mood swing means that the episodes of mania and depression shift from one pole to the other. This can happen over and over again. If the shifts occur at least four times a year, the illness is called rapid cycling.
A mixed episode is when mania and depression fluctuate so quickly that they seem to occur at the same time, or when symptoms that meet the criteria for a manic and a depressive episode actually do occur at the same time. Indeed, the “poles” of bipolar disorder are not entirely opposites; if you read about the symptoms, you will see they overlap.
Sometimes the term mixed mania is used when manic features predominate but there are also substantial symptoms of depression. Similarly, there are states of energetic or agitated depression—in which depression dominates but features of mania exist at the same time.

The Disorders

The most commonly used official diagnostic criteria for bipolar disorders are given in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition, called by its initials: DSM-IV-TR—the principal guidebook for psychiatrists. (You’ll find excerpts from the complete clinical criteria at the end of this book.) Although at first glance these criteria may seem clear, in practice a diagnosis of BD is not a simple one to make, primarily because BD is often confused with other disorders with similar features. In fact, it has been estimated that the average bipolar patient suffers through ten years of symptoms before receiving a correct diagnosis.
The DSM-IV-TR and most other official criteria recognize multiple forms of bipolar disorder. The primary forms are bipolar 1 and bipolar 2.

Bipolar 1 Disorder

According to the DSM-IV-TR,
The essential feature of Bipolar I Disorder is a clinical course that is characterized by the occurrence of at least one, and usually more, so-called Manic Episodes or Mixed Episodes. Often individuals have already had one or more Major Depressive Episodes. Sometimes, the individual is experiencing a first episode of illness (i.e., Single Manic Episode). More commonly, the disorder is recurrent. Recurrence is indicated by either a shift in the polarity of the episode, from manic to depressed or vice versa, or by an interval between episodes of at least two months without symptoms of illness.
The illness is said to be chronic if an episode never fully ends, and significant symptoms remain; it is recurrent if there are new episodes of illness separated from previous episodes by at least a few months.
Bipolar 1 patients do not just have extremes of mood. They may also experience hallucinations and, more commonly, delusions. For this reason, BD is considered a psychosis.
Hallucinations are false sensory perceptions. In BD, these are usually auditory (such as hearing voices) or visual (seeing things that are not there). Often these voices or visions are related to the episode of illness. They are often consistent with the high mood and grandiosity of mania (the victim might believe she hears voices of angels or God), or with despondency in depression (the voices might tell him he is worthless or disgusting).
Delusions are false and odd beliefs. As with hallucinations, in BD they are often consistent with the prevailing mood. A person who is manic may believe he has exceptional, even superhuman, strength or prowess. An individual who is depressed might believe she is rotting or beset by demons. Delusions of grandeur or persecution are the most common delusions in people with bipolar 1 disorder. (We’ll look at these in a little more detail later in this chapter.)
In lay terms, bipolar 1 is the classic form. It is what most people think of when they hear the terms bipolar or manic-depressive: the recurring experience of big highs (mania) and big lows (depression). But it is not the only type of bipolar disorder.

Bipolar 2 Disorder

According to the DSM-IV-TR, “The essential feature of Bipolar II Disorder is a clinical course that is characterized by the occurrence of one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode.”
Hypomania can be characterized by abundant energy, confidence, and other seemingly “good” emotions and states—or, like mania, it can be associated with disconcerting irritability. In people suffering from bipolar 2, this mood state often precedes an episode of serious depression.
A person suffering from bipolar 2 disorder may not appear to be as “clearly manic-depressive” to the observer, especially when the person just seems to be in a particularly good mood. But it can be just as serious a disorder as bipolar 1, because the depressions can be just as deep.
Is There a “Bipolar 3”?
Some people seem to experience episodes of bipolar disorder only in the context of a general medical illness, such as multiple sclerosis or thyroid disease, or only after exposure to a drug, such as a steroid medication or a stimulant. The term bipolar 3 is often used to describe bipolar disorder apparently induced by prescription or nonprescription drugs.
Of particular importance, medication prescribed for a diagnosed depression will sometimes give rise to mania or hypomania instead of just restoring normal mood. This may be the first evidence that someone suffering a depression has a form of illness related to bipolar disorder. The relationship between these forms of the disorder and bipolar 1 and 2 is not clear; but, in addition to symptoms, all probably share some underlying physical characteristics, including inherited factors that determine the risks of becoming ill.
Human conditions are rarely fully described by neat lists of symptoms and specific criteria, and so it is with bipolar disorder. Many people have symptoms of BD, but don’t quite fit the criteria in the textbooks. The DSM-IV-TR classifies such people as Bipolar Disorder Not Otherwise Specified, or BD-NOS, another term you may have heard. People who have BD-NOS can experience some or most of the elements of mania and depression, but not enough to meet the specific criteria for Bipolar 1 or 2 Disorder in the DSM-IV-TR. Cyclothymia is frequently found in relatives of people who have bipolar disorder. This much milder version of BD includes both depressions and hypomanias, and mood may shift much more rapidly than in other forms of bipolar disorder. Although less severe than bipolar 1 and 2, it can cause problems in daily life and relationships. Over time, it may evolve into other forms of BD.
So: Is there really a bipolar 3? There is no consensus on this issue. Some people speak of bipolar 3 and even 4 and 5, but there is no general agreement as to use. The DSM-IV-TR does not use “bipolar 3.” These terms can mean different things to different experts.

GOING TO EXTREMES: BIPOLAR BEHAVIORS

Most of us have restless nights when we can’t sleep, days when we feel irritable and touchy, moments of being impulsive or doing something that in retrospect seems foolish. For people with bipolar disorder, however, these common occurrences become magnified.
People who have bipolar disorder are more likely, when manic, to engage in all kinds of dangerous activities—from embarking on affairs to engaging prostitutes to driving recklessly or running around dodgy neighborhoods in the middle of the night to quitting needed jobs with no thought about the consequences. People with untreated BD may even commit crimes or impulsively injure themselves or others, as a consequence of their illness. (In fact, an estimated forty thousand people in the U.S. prison system suffer from bipolar disorder.)
You might notice that your spouse or partner constantly seems to invade your privacy—opening your mail or e-mail, listening in on private conversations, or asking invasive questions. Intense curiosity can also be a part of bipolar disorder.
For some people who have bipolar disorder, self-centeredness can be extreme. A bipolar person might not see his or her viewpoint as the right one, so much as the only one. You might sometimes find, to your frustration, that your feelings, opinions, wishes, and conversation hardly seem to matter. When ill, your partner might appear blatantly selfish. Your partner might also misunderstand things you or others do or say, or give such convoluted rationales for his own actions or thoughts as to leave you shaking your head—or banging it (figuratively, we hope) into the nearest wall.
Even more frustrating for their partners, people who have bipolar disorder often don’t believe that their extreme moods and unusual behaviors are part of an illness—or even abnormal. A bipolar person may not feel distressed or may believe that his distress is only circumstantial, that a new job or the improvement of a stressful situation (or you!) would make the problems disappear. Doctors call this a “lack of insight.”
To someone with bipolar disorder, BD is mostly about extreme moods and altered thinking. To the rest of us, it’s about the behaviors that go with those symptoms. Understanding the types of behaviors that are typical of bipolar illness might help you understand and talk to your spouse or partner about his symptoms, actions, and beliefs. Let’s look at a few of the more common and obvious behaviors.

Sleeplessness

During manic episodes, along with increased energy and activity throughout the day, wakefulness is common. Bipolar sufferers may report not feeling the need to sleep or being kept awake by tormented, “racing”—that is, rapid, numerous, and changing—thoughts. They might even stay awake, or mostly so, for days at a time—which can lead to dangerous physical exhaustion and contribute to many other extreme behaviors. Or they may sleep for only an hour or two a night—then make up the loss by sleeping away the better part of a day or two.

Extreme Irritability

If you’re living with someone who’s living with bipolar disorder, you’ve no doubt noticed extreme irritability—or downright nastiness—creeping into your conversations, perhaps for prolonged periods. Often these statements and behaviors are exaggerated reactions to real events or annoyances; sometimes they’re irrational, and would look that way to any observer. During these times, you or others might be subjected to seemingly nonsensical rants, blame throwing, and verbal threats or challenges. You may even be subject to inappropriate physical actions, such as breaking or throwing objects, or even assault.
You might also notice undue anger. We’re not talking about the angry feelings most people experience from day to day, but extreme displeasure, criticism, or irrational fury directed at life in general, a frustrating situation, or you in particular. You might be accused of having done something “wrong.” You might also get blamed for far more than you deserve. You may feel as if—at least, in the eyes of your spouse—you can do nothing right.
007
LIVING WITH BD
Bob and Tanya
 
For ten years of marriage I’ve adjusted my behavior to my wife’s outbursts. I figured that I must be the cause of her rage—I know I can be sloppy, I don’t always pick up after myself, sometimes I (continued) forget to lock the door when I go out . . . you know, stuff like that. Tanya constantly picks fights with me about my shortcomings—of course, she calls them something worse than that—and I always apologize and promise to do better, but there’s always something.
That’s bad enough. But the really annoying thing is that after she’s gotten it all off her chest, and I’m just exhausted from the whole thing, she’s all sunny smiles and energy. If I criticize her, I get another earful as to how wrong I am.

Extreme Talkativeness

Many people who suffer from BD talk incessantly during manic phases. People who have bipolar 1 may even talk themselves hoarse! (That doesn’t necessarily end the behavior, however.) To a lesser degree, they may become abnormally “chatty,” oblivious to the fact that another person who may wish to join in the conversation can’t get a word in.

Distractibility, Tangentiality, and Inability to Concentrate

A person with BD can switch hastily and frequently from one project to another. Psychiatrists call this distractibility, an apt description. Your partner may begin to fix a leaky pipe, for example, only to drop all the tools on the floor and begin working at the computer on a writing project, only to become engrossed a short while later in cleaning the mildew from the shower.
You might also notice the person changing topics rapidly or drifting quickly away from the subject at hand. (Psychiatrists call this tangentiality.) The speaker might seem to jump from point to point without necessarily taking the listener along, which can be disorienting if you are seriously trying to follow the train of thought.

Overspending and Excessive Gambling

Overspending is a problem frequently seen in people who have bipolar disorder, and one that can wreak havoc in a relationship based on shared finances. Some of the stories seem too fantastic to be true: a man buys two new Maseratis in one day (and doesn’t even have a driver’s license!). A woman flies to Las Vegas at the spur of the moment and proceeds to lose $15,000 in an afternoon. A grandmother of six stays in the house all day wearing the same sweat suit while purchasing thousands of dollars worth of clothing (delivered, but unopened and never returned) from a home shopping channel on television. A man goes to the grocery store and spends hundreds of dollars on exotic fruits and vegetables that go bad quickly because his refrigerator is already stuffed full of uneaten groceries.

Hypersexuality

Some people who are bipolar find themselves overwhelmed with sexual thoughts and impulses during manic episodes. This can lead to unhealthy affairs, marital tensions, and breakups. One man reports that during manic episodes, his wife not only demanded sex from him several times a day but regularly had four or five casual affairs with men she barely knew. (Conversely, a very depressed partner might, for long stretches, demonstrate virtually no interest in sex.)

Substance Abuse

Substance abuse can be a sign of bipolar disorder. It is important to be aware that people with BD often use sedatives for sleep, alcohol for anxiety, and stimulants to raise mood. In part, they are probably treating their symptoms; in part, they are exercising the bad judgment and impulsivity typical of BD.
What Are the Symptoms of Bipolar Disorder?
According to the National Institute of Mental Health, these changes in behavior and mood may signal bipolar disorder.
 
Signs and symptoms of mania (or a manic episode) include the following:
• Increased energy, activity, and restlessness
• Excessively ‘high,’ overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking very fast, jumping from one idea to another
• Distractibility; can’t concentrate well
• Little sleep needed
• Unrealistic beliefs in one’s abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong
• A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present.
Signs and symptoms of depression (or a depressive episode) include the following:
• Lasting sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy; a feeling of fatigue or of being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much, or can’t sleep
• Change in appetite and/or unintended weight loss or gain
• Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
• Thoughts of death or suicide, or suicide attempts

PSYCHOTIC SYMPTOMS

Psychotic symptoms—the most common being delusions of grandeur or persecution—can be very upsetting. During a manic episode, people often believe themselves capable of much more than they are. They might suddenly think they possess great brilliance, insight, or other intellectual abilities or great strength or physical skills. Such enthusiasm and unquestioning belief in the truth of what they are saying can be hard to resist, especially the first time you experience it. It can also be dangerous.
Perhaps your partner managed to convince you, during such an episode, that your money problems were—or soon would be—over, or that a great opportunity beckoned, just over the horizon. You might get swept up into investing time, enthusiasm, or money, only to find yourself disappointed later, when the “opportunity” fails to materialize.
Delusions can cause the sufferer to make irrational decisions. She might suddenly drop a long-term friendship, saying her former friend has been systematically poisoning her friends against her. Or he might quit his job because he knows he will be offered the chance of a lifetime later this afternoon. One woman told her boyfriend that she had to break off their relationship that afternoon because it was critical for her to move to Mexico that day to open a spiritually based health care clinic that would save humankind from the coming plague.
Your partner’s delusions could be considerably more disturbing. She might tell you that others are “persecuting” or keeping watch over her or even controlling her, sending her secret messages in the daily newspaper, with which she has papered the walls of the bathroom. One man described having the conviction that he was Truman in The Truman Show—watched by TV cameras and living a scripted life, and that he might have to kill the director.
If you have ever witnessed your spouse or partner in the grip of a paranoid delusion—suddenly swearing that he’s being watched or monitored, or making unfounded accusations toward you or others—you know how frightening such an episode can be.
 
In the late nineteenth century, a German psychiatrist named Dr. Emil Kraepelin (1856-1926), after observing thousands of patients with the same troubling symptoms, coined the term manic-depressive illness. He also made many of the distinctions that became the basis of what we now call bipolar disorder (somewhat similar to what he called “manic depression”) and schizophrenia (somewhat similar to what he called “dementia praecox”). This marked a milestone in our modern understanding of bipolar disorder. But human awareness of the condition, as we will see in the next chapter, goes back much farther.

008
CHAPTER 2
A Brief, Colorful History (and Some Science) of Bipolar Disorder
Had [Winston Churchill] been a stable and equable man, he could never have inspired the nation. In 1940, when all the odds were against Britain, a leader of sober judgment might well have concluded that we were finished.
—Anthony Storr (1920-2001)
 
Even a cursory glance at the history of bipolar disorder tells us one very important fact: bipolar individuals are and have always been a part of our society. Despite the demonization and stigmatization of the mentally ill throughout human history, most have played typical roles, and their illness was little noted. It is also clear that some people struggling with bipolar disorder or those believed to have been bipolar—from Beethoven to Winston Churchill, Dick Cavett, and Francis Ford Coppola—have played vital roles in human history and made enormous contributions to culture. Of course, they were usually most productive when their symptoms were absent or minimal. It has only been recently—since the second half of the twentieth century, in fact—that doctors could begin to effectively treat the most serious symptoms of BD. Management of the illness today is still not perfect, but it is a long way ahead of where it once was.

FROM MANIA AND MELANCHOLIA TO BIPOLAR DISORDER

Physicians as far back as ancient Greece recognized BD’s two emotional and behavioral extremes as one illness—and recorded its symptoms with uncanny accuracy. In particular, Aretaeus of Cappadocia (a part of modern Turkey), believed to have lived in the first century (c. 30-90), described patients who “desired to die” or became “dispirited” and “sleepless.” His description could be used today: “Melancholia is the beginning and a part of mania. . . . The development of a mania is really a worsening of the disease (melancholia) rather than a change into another disease.” He also noted the increased sexuality of mania, among other symptoms we still recognize today, and made the connection between mania (the term he used) and melancholia (his term for depression).