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 profound weaknesses in confidence. The ability to uncover and to resolve anger contributes to stabilizing the mood in those with this illness.

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

Bipolar II Disorder involves Major Depressive Episodes and Hypomanic Episodes. 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.

Anger in Bipolar Disorders

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. Research has shown that depressed bipolar clients are less angry than unipolar clients (Beigel & Murphy, 1971). Also, Jain, et al (1997) found that clients with unipolar major depressive disorder were significantly more likely to report anger attacks than bipolar clients during a depressive episode.

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.

Reasons for Hope

Irritability and excessive anger are major mood disruptions that are common in clients 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 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.