The Bipolar II Conundrum: Neurochemical Disorder vs. Personal Responsibility

Bipolar, Neurochemistry and Personal Responsibility

Posted Mar 14, 2010

For those with bipolar disorder, and particularly for those with Bipolar II (see my blog from 2/18/10), symptoms in the mild to moderate range can often give rise to feelings of guilt and self-doubt. Essentially Bipolar II individuals are left with the question: "What am I responsible for vs. what do I have little control over as a result of my illness?" After all, when viewed as a neurochemical disorder it would seem that the shifts in mood and energy, either upwards or downwards, aren't usually subject to conscious control by the bipolar individual. If they were, then bipolar disorder probably wouldn't be a diagnosable illness. It would just be a reflection of poor choices. Maybe we could call it "Poor Judgment Disorder."

But all you have to do is speak with several who have the disorder and you'll learn that much of their experience is beyond their conscious control. It isn't like they can simply feel more upbeat when slipping into depression, or conversely, put the brakes on when energy and cognition are accelerated due to hypomania. The person with bipolar disorder often feels like they're on a raft being carried down a river. Sometimes they reach parts of their journey where the water is still or hardly moving at all. At other times they're being swiftly carried down river while also trying to manage turbulent rapids. In other words, being told they can exert control is like being subject to a cruel joke.

This analogy is quite clear if we're referring to the class IV or V rapids of full mania. In fact for those with Bipolar I there is often little ambiguity about being out of control. The very fact that full mania requires the safety and protection of inpatient hospitalization as well as fairly strong medication to bring the individual's behaviors back under control is usually a clear testament to the fact that the manic person is experiencing neurochemistry gone awry. When I'm seeing someone in outpatient therapy following discharge from a hospitalization, he or she may indeed feel embarrassed by the behaviors which brought about the hospitalization, but the individual rarely feels like he or she had a lot of conscious choices. Consequently, his or her sense of guilt is a lot less palpable than someone with Bipolar II.

Let's imagine that last week Jamie, who is in her second year of college, was experiencing the early phases of Bipoar II hypomania. Her mood was cheerful and she felt energized. She only slept four hours nightly. She was also really up for having a good time. On three weekday nights she went out drinking with friends. During one of those nights, she hooked up with someone she barely knew. She also blew off four different classes during the week because she simply didn't care. Things were feeling too good to be bothered by the banality of going to class. By Friday of the week she was starting to feel a bit worn out and things were made far worse by the fact that she had a test in her history class that she completely forgot about. That's when it all crashed and Jamie's sense of emotional buoyancy gave way to the sinking feeling of failure and depression. From Jamie's perspective and from those who knew her but didn't know about her disorder, she had really screwed up.

But had she? Had she really started the week with the intent of creating a disaster? Or, had she simply reached a point in the river where her paddling skills weren't strong enough to manage the turbulence? And then even with this analogy could she have handled things better if she were more skilled on the river?

The answer probably lies somewhere between. But the point is, those of you with Bipolar II are frequently faced with pervasive guilt and self-doubt about your own role in creating negative outcomes as a result of your episodes of destabilization. Consequently, your work needs to occur in two areas. First, you really need to work on compassion and self-acceptance. You don't desire irresponsibility but your hypomania creates the impulsivity that leads to irresponsibility. Second, you really need to become world-class paddlers. There are many skills and many behavioral adaptations that can be applied which will help you smooth out the turbulent waters. Those who have lived with bipolar disorder for numerous years are typically better at these skills as they've had a longer period of practice. Those who are newer to the river aren't as skilled.

Unfortunately, those you with bipolar disorder don't typically have a choice as to what river you're going to raft. That's where we see the differences between Bipolar I and II. But once on the river, you're not without paddles. How effectively you apply your skills can make a big difference. And don't forget that acceptance of the fact that you have a disorder is one of these necessary skills!

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Russ Federman is co-author of Facing Bipolar: The Young Adult's Guide to Dealing with Bipolar (New Harbinger Publications), see