The Spouse/Relative with Bipolar Disorder

In this chapter the uncovering and treatment of the emotional conflicts in bipolar disorders is discussed. Difficulties with excessive anger have been well documented both in research studies and in clinical experience. This anger is regularly associated with strong sadness and loneliness and also significant weaknesses in confidence. The ability to uncover and to resolve anger contributes to stabilizing the mood in those with this illness and in preventing relapses.

Let's look now at the criteria from the DSM IV for making the diagnosis of Bipolar I.

Criteria for Making the diagnosis of Bipolar I (Mania)

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week (or any duration if hospitalization is necessary).

B. If during the period of mood disturbance, three or more of the following symptoms have persisted and have been present to a significant degree:

  1. inflated self-esteem or grandiosity
  2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3. more talkative than usual or pressure to keep talking
  4. flight of ideas or subjective experience that thoughts are racing
  5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Hypomania

Another psychiatric disorder which is not as severe as a bipolar disorder is hypomania. Listed below are the criteria for a hypomanic episode.

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B. During the period of mood disturbance, three or more of the following symptoms have persisted and have been present to a significant degree:

  1. inflated self-esteem or grandiosity
  2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  3. more talkative than usual or pressure to keep talking
  4. flight of ideas or subjective experience that thoughts are racing
  5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Bipolar II Disorder

DSM-5 states that, "The vast majority of individuals whose symptoms meet the criteria for a fully syndromal manic episode also experience major depressive episodes during the course of their lives." Bipolar II, requires the lifetime experience of at least one episode of major depression and at least one hypomanic episode, is, according to DSM-5, ” no longer thought to be a milder condition than bipolar I disorder, largely because of the amount of time individuals with this condition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and in social functioning.” Bipolar II has been viewed as the most common phenotype of bipolar disorder (Simpson, et al., 1993)  Bipolar II is often a first step to Bipolar I. Over 5 years, between 5% and 15% of those will Bipolar II will change diagnosis to Bipolar I. Approximately 0.5% of people will develop Bipolar II in their lifetimes.

Increased Prevalence of Bipolar Disorders (BP)

Research studies are demonstrating a marked increase in the prevalence of Bipolar Disorders. In a Spanish study the estimated annual number of youth office-based visits with a diagnosis of bipolar disorder increased from 25 (1994-1995) to 1003 (2002-2003) visits per 100,000 population, and adult visits with a diagnosis of bipolar disorder increased from 905 to 1679 visits per 100,000 population during this period. In 1999 to 2003, most youth bipolar disorder visits were by males (66.5%), whereas most adult bipolar disorder visits were by females (67.6%); youth were more likely than adults to receive a comorbid diagnosis of attention-deficit/hyperactivity disorder (32.2% vs 3.0%, and most youth (90.6%) and adults (86.4%) received a psychotropic medication during bipolar disorder visits, with comparable rates of mood stabilizers, antipsychotics, and antidepressants prescribed for both age groups. (Moreno, et al., 2007.)

Anger in Bipolar Disorders (BP)

Irritability, a manifestation of anger, is one of the more common mood symptoms seen during mania and it is often the predominant mood. DSM-5 states, “A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persisitently increased goal-directed activity or energy, lasting at least one week and persistent most of the day, nearly every day is necessary, DSM-5.” In Goodwin and Jamison’s summary of numerous studies 80% of adult clients manifested irritability during mania (Goodwin & Jamison, 1990).

Individuals with BP display greater rates of anger and aggressive behaviors, especially during acute and psychotic episodes, with no effects of BP subtype. Researchers recommend early identification and management of these behaviors (Ballester,, et al., 2012). Anger dyscontrol has been shown to be more prominent for youth with BD, whereas disordered thought content was paramount for adults (Safer, et al., 2010). Rage, irritability, and long episodes are common manifestations of mania in young people with bipolar disorder. Frequent comorbid disorders in young patients include ADHD and anxiety disorders (Chang, 2010). In a study of 130 consecutively evaluated children and adolescents with BD, 48.5% of the youth had rage attacks (Staton, et al., 2008).

Also, available evidence indicates that a prodrome to bipolar disorder exists. Commonly encountered features preceding the onset of a manic episode are affective lability, irritability, anger, depression, anxiety, substance use disorders, sleep disorders, as well as disturbances in attention and cognition (Brietzke, Mansur, Soczynska, Kapczinski, Bressan, & McIntyre, 2012). Other researchers stated that is likely that an approach aimed at the identification of impending first-episode mania is the most realistic and manageable strategy to promote earlier treatment. During the period preceding the onset of the first manic episode, patients go through a prodromal phase marked by the presence of mood fluctuation, sleep disturbance, and other symptoms such as irritability, anger, or functional impairment (Conus, Ward, Hallam, Lucas, Macneil, McGorry & Berk, 2008). 

 A 2013 study revealed that most bipolar youth eventually experienced both irritability and elation irrespective of history. Irritable-only youth were at similar risk for mania but at greater risk for depression compared with elated-only youth and youth who had both irritability and elation symptoms (Hunt, et al., 2013).

Bipolar disorder among adults is the axis I disorder most strongly associated with substance abuse disorders (SUD). At least 50% of adults with BD meet the criteria for SUD at some point in their lives (Grant, et al., 2004). Substance abuse in adults with BD is associated with reduced medication adherence and quality of life, delayed recovery, hastened relapse and increased functional impairment, suicide attempts, violence, and polarity switches into mania (Salloum & Thase, 2000). Also, in study of adolescent BD, first-onset Substance Abuse Disorder developed in 32% of the subjects. Lifetime oppositional defiant disorder and panic disorder, family history of SUD, low family cohesiveness, and absence of antidepressant treatment at intake were also associated with increased risk of SUD, whereas BP subtype was not. (Goldstein, et al., 2013.)

Irritability, a manifestation of anger, is one of the more common mood symptoms seen and it is often the predominant mood during mania. The lability of the mood between euphoria and irritability is frequently seen in mania (DSM-IV). In one major study 80% of adult clients manifested irritability during mania (Goodwin & Jamison, 1990).

Davis (1979) observed that children with BPD were highly irritable and had prolonged and aggressive temper outbursts. In Carlson's study (1995) children with BPD were severely irritable, dysphoric, and agitated. Biederman (1998) has stated that children with BPD may not present with the classic adult manic picture, but instead, as several studies have shown, they present with a more chronic, irritable, and dysphoric course (McElroy et al, 1997; Weinberg and Brumback, 1976). In a study (Wozniak, et al, 1995) of preadolescent children who met the diagnostic criteria for mania, the clinical picture was characterized by severe irritability and their presentation was predominantly mixed with symptoms of major depression and mania co-occurring.

In the review of ten years of research into child and adolescent BPD, Geller and Luby (1997) suggest that prepubertal- onset BPD may be comorbid with ADHD and CD (conduct disorder) or have features of ADHD and/or CD as initial manifestations. Comorbid conduct disorder may exist in a significant portion of young clients with bipolar disorder. Wicki and Angst (1991) reported in their study of the association between conduct problems and bipolarity that hypomanic cases presented more disciplinary difficulties at school when they were young and had reported more frequent thefts during their adolescent years than the rest of the cohort. In Kutcher's (1989) study of the comorbidity of conduct disorder with other Axis I conditions, he found that 42% of the bipolar clients had secondary conduct disorder. Also, comorbid conduct disorder in bipolar youths appears to be associated with a worse clinical course (Kovacs & Pollock, 1995). In another study of mania in children, 91% had lifetime comorbid ODD and 86% lifetime comordbid ADHD (Biederman, et. al, 1998). Manic episodes in adolescents may be associated with excessive anger as manifested in school truancy, antisocial behavior, school failure, or substance use.

Our clinical experience indicates that the majority of clients with Bipolar II Disorder, in which one or more major depressive episodes are accompanied by at least one hypomanic episode, also periodically struggle with strong anger. This anger is associated with their depressive disorder and may or may not manifest itself in a more extreme manner as an anger attack. However, there is no empirical research yet to support this clinical view.

Origins of Anger in Bipolar Disorders

Goodwin and Jamison (1990) identify a number of organic causes of manic and hypomanic symptoms. Neuroendocrine studies may later identify a neurotransmitter abnormality which influences the excessive irritability and, at times, rage is seen in clients with bipolar disorders.

The psychological origin of the anger in these persons is similar to those in other disorders presented in the depression, anxiety and marital anger chapters on this website. However, in grandiose male clients we find that the most often identified source of anger is from conflicts and hurts in the father relationship. Numerous manic young males in their late teens and early twenties have reported very painful father relationships in which they were never affirmed in their masculinity or in which they were subjected to excessive unwarranted criticism. The resultant anger from such disappointments in the father relationship is associated with a profound sense of male insecurity. The resentment is rarely directed at the father because of the fears of him, of one's anger with him and of losing the fragile relationship. Instead, these males regularly overreact in anger at others who are undeserving. Both grandiose thinking and hyperactivity in these males seem to be an unconscious attempt to compensate for their profound sense of male inadequacy.

In many young females with bipolar disorder a frequently encountered source of irritability and rage is strong, disabling loneliness. This loneliness is associated with strong feelings of sadness that have been denied regularly. These young women present a very labile mood alternating between great irritability and euphoria which is a reaction formation to their underlying loneliness and sadness. They may be angry with men who have hurt them or even at God. Also, it is not unusual to uncover anger in these young women arising from childhood and adolescent experiences of loneliness in a parental relationship.

Forgiveness in Bipolar Disorders

Forgiveness can provide a new method for dealing with angry feelings and can play an important role in helping to stabilize the mood of bipolar clients by diminishing their intense irritability or rage. Therapists usually encounter little resistance in these clients regarding the uncovering of their resentment. After their mood has been stabilized, when asked to describe who has disappointed them most in childhood, adolescence, and adulthood, they usually are open and cooperative. However, until they have begun to work at forgiving on a regular basis, their anger can sometimes be misdirected at the therapist.

Male Confidence Conflicts and Bipolar Disorders

Ben had his first manic episode during the summer before he began college. He was the second of two children and had been a straight A high school student and had been looking forward to starting college in the fall. He was seen in consultation on an inpatient unit during the third week of his psychiatric hospitalization. His mood continued to be quite labile alternating between euphoria and depression and he had not responded well to medications. In addition, he had developed a number of troubling side effects from the antipsychotic drugs.

During the first session he was asked if he could identify anyone who had hurt him over the course of the summer. He responded by crying uncontrollably for a prolonged period of time. He then began cursing his father for the constant ridicule to which he had subjected him during the summer. Ben related: "My father was always calling me a dumb shit, just because I couldn't do the kind of things he could do with his hands. I have more brains than he'll ever have," he added. The history revealed that he had never felt close to his father, but, in time, he came to recognize that his dad was an unhappy and depressed individual and he came to better understand him.

After forgiveness was explained as a method that could provide freedom from his anger toward his father, Ben quickly committed himself to working at forgiving him. At times he felt so angry with his father that he had to live with his anger and discuss it at length before continuing the work of forgiveness. After his anger diminished, sessions were held with his father during which Ben was able to express how hurt he had felt in their relationship. Later, he expressed his desire to let go of his resentment toward his father in the hope that their relationship might improve. His moods during these sessions alternated between intense sadness with prolonged periods of crying and strong irritability toward his father. This catharsis with his father helped Ben greatly. Initially defensive, his father was able to apologize, in time, and commit himself to the process of recognizing his son's abilities and learning to encourage rather than belittle him.

The slow resolution of his strong anger with his father over several months resulted in emotional stabilization. This young man spent several years working to understand how hurt his father had been as a boy, trying to resolve his anger toward a sad, overly critical parent. The most difficult aspect of the forgiveness process was to accept the pain of never having the type of father relationship he had hoped for when he was a young boy and an adolescent. He did, however, feel hopeful that the relationship with his father would improve if they both focused on the opportunities ahead rather than the failure behind.

Also, the virtue of faith helped this young man. He reported that a discussion with his minister of God as his other loving father at every life stage to be both comforting and strengthening. He reported that he was helped by specifically meditating during the day that God had given him special gifts, especially during times of stress.

Female Loneliness Conflicts and Bipolar Disorders

Demi was an extroverted and warm twenty- six -year old professional who had had two previous manic episodes that required brief hospitalizations. She recovered quickly and returned to her work after she had been placed on lithium. When her mood was stable she related that she was rarely angry. During her manic episodes, however, she manifested uncharacteristic hostility and explosive rage. When she was asked at her first session what she thought was the cause of her anger when she was manic, she responded angrily, "I can't stand the loneliness in my life. I want to get married and have a family but there doesn't seem to be a decent man out there. In the end everyone I go out with winds up hurting me."

Demi came to recognize that in the past she had been spending a great deal of energy in the attempt to deny both her loneliness and anger. She liked the idea of honestly facing her anger and trying to resolve it in a manner in which neither she nor others would be harmed. Enthusiastically, she began the work of forgiving the men who had hurt her because, intuitively, she sensed that it would help heal the pain of the past and free her from unnecessary baggage. However, she was not able to accept the loneliness associated with being single. Even though she worked at forgiving she still periodically hated the pain of loneliness in her life.

Her mood was stable for many months until the approach of mid- November of that year. Then she began to obsess about spending Thanksgiving, Christmas, and New Year's without a special boyfriend whom she could really trust. After Thanksgiving she suddenly became manic and was hospitalized again. During that time she was surprised to discover within herself a strong anger against God. She stated, "Why hasn't God brought the right man into my life? He's done this for many of my friends. What does He have against me? What have I done wrong?"

The expression of this anger was very helpful for her, although at first she was uncomfortable with the notion of thinking of forgiving God. However, Demi had come to realize that this was the most effective method of resolving her anger and she committed herself to this unusual type of forgiveness, especially when she felt lonely or cheated.

After her hospitalization, Demi returned to work and continued to employ forgiveness to help control anger and stabilize her mood. Although she continued to struggle with loneliness for years, she had no depressive episodes. Like Ben, her faith helped her. She meditated upon God's special love for her which was a source of comfort. Later she married happily and there have been no further manic episodes for the five years of her marriage.

Medication in Youth with Bipolar Disorders

Atypical antipsychotic drugs are regularly prescribed for the treatment of BD in children and adolescents in addition to mood stabilizing medication. In the United States, the estimated number of office-based visits by youth that included antipsychotic treatment increased from approximately 201 000 in 1993 to 1 224 000 in 2002. From 2000 to 2002, the number of visits that included antipsychotic treatment was significantly higher for male youth (1913 visits per 100 000 population) than for female youth (739 visits per 100 000 population), and for white non-Hispanic youth (1515 visits per 100 000 population) than for youth of other racial or ethnic groups (426 visits per 100 000 population). Overall, 9.2% of mental health visits and 18.3% of visits to psychiatrists included antipsychotic treatment. From 2000 to 2002, 92.3% of visits with prescription of an antipsychotic included a second-generation medication. Mental health visits with prescription of an antipsychotic included patients with diagnoses of disruptive behavior disorders (37.8%), mood disorders (31.8%), pervasive developmental disorders or mental retardation (17.3%), and psychotic disorders (14.2%) (Olfson, et al., 2006).

The trends in prescriptions of antipsychotics within the Texas Medicaid Program demonstrated that the prevalence of atypical antipsychotic use increased by almost 500% over 5 years, with an increase of 609% in children 5 to 9 years old (Patel, Sanchez, Johnsrud & Crismon, 2002). Nearly 25% of youth on antipsychotic medication in one study were were aged nine years or younger and nearly 80% of these were boys (Curtis, Masselink, Ostbye, Hutchinson, Dans, Wright, Krishman & Schulman, 2005). Also prominent differences in psychotropic medication treatment patterns exist between youth in the US and Western Europe with 1.5-2.2 greater use in the U.S.( Zito, et al., 2008)

Other treatment options for excessive anger in youth with BD, such as forgiveness therapy, need to be considered in view of the recent reports of serious side effects from the use of atypical antipsychotics. Specifially, a 2013 retrospective cohort study of youth in the Tennessee Medicaid program with 28,?858 recent initiators of antipsychotic drugs and 14,?429 matched controls showed that the users of antipsychotics had a 3-fold increased risk for type 2 diabetes that increased with cumulative dose (Bobo, et al., 2013).

Bipolar Disorder II

A French study found that at index interview 22% of major depressive patients could be diagnosed as bipolar II based on past history of hypomania. Upon interview a month later 40% of patients were diagnosed as bipolar II on the basis of a more in-depth evaluation and collateral information from significant others, as well as observed hypomania by the clinician (Hantouche, et. al.,1998). Another review of 493 persons diagnosed initially with major depressive episode (MDE), found that the BP-II rate was estimated at index at 20%; 1 month later and systematic probing for hypomania doubled the rate of BP-II to 39% (Akiskal, et al., 2006).

Bipolar II disorder is also associated with strong irritability in its hypomanic and depressive phases. Bipolar depression anger attacks are common (Mammen, et al., 2004.) The current, limited evidence supports the following lines of treatment for BP-II: hypomania is likely to respond to the same agents useful for mania, i.e. mood-stabilizing agents such as lithium and valproate, and the second-generation antipsychotics. The only preventive treatment for both depression and hypomania that is supported by several, albeit older, controlled studies is lithium. Lamotrigine has shown some efficacy in delaying depression recurrences, but there have also been several negative unpublished studies of the drug in this indication (Benazzi, 2007).

Reasons for Hope

Irritability and excessive anger are major mood disruptions that are common in people with bipolar disorder. The failure to resolve and control this anger results in marked mood instability and relapses and in significant mental suffering in the individual and turmoil in the family. Forgiveness therapy is an effective psychotherapeutic practice that individuals with bipolar disorder can employ to control and to resolve their strong anger.

Spouses and family members should have the freedom to recommend that loved ones with bipolar disorders think about trying to control and to resolve their strong anger through use of the virtue of forgiveness. We have worked with many individuals whose bipolar illness was not stabilized until they made a daily commitment to uncover and to resolve their resentment.