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Bipolar Disorder

Bipolar Irritability: Often Overlooked and Underestimated

Diagnostic Implications of Bipolar Irritability

At age 23, Keith has been depressed on and off for the last four years. He also has no clue as to why. He had a happy childhood with very supportive parents. He did well in college and he's now in his first year of employment as a high school science teacher. Keith has also been in a love relationship for the last eight months and his friendships are similarly quite good. While there are intermittent times when Keith feels just fine he repeatedly finds that for no apparent reason he becomes really unhappy. He doesn't just feel sad, blue or down. It's more like he feels miserable with a sharp edge of discontent. In the midst of his negativity everything grates on him. During these episodes which can last up to a couple of weeks he can't seem to get comfortable with himself or with others. He just wants to snap at the people he cares for, all the while knowing they don't deserve his negativity. So rather than approaching social situations like an agitated porcupine, he prefers to withdraw to his bedroom hoping for some respite. Unfortunately, it doesn't come. With each episode he feels more and more prickly.

Erika is 19 and finishing up her first year of college. She did well during her first semester, attaining Dean's list while also establishing some excellent new friendships. Spring semester also got off to a good start - no major hassles. But beginning early April, Erika found herself frequently feeling like she was tied in knots. She was keeping up with school work and generally remaining on top of things. Despite her relatively low degree of external stress she was having difficulty getting more than a few hours sleep at night. She also found her mind was darting about with unusual speed. When she was in this mildly agitated state Erika reacted to her friends more like they were poison than a source of healthy support. She knew something was wrong but had no clue as to what it might be. She did know that her generally positive nature was transforming into her version of Erica the Witch.

Shawn, at age 20, had always been fairly chill, despite getting a full ride to play tennis at a top-ranked school. He had a lot going for him and he was well liked by his peers. In fact people would often comment on how easy-going he could be while also accomplishing so much. Granted, he was strongly dedicated to his sport, but he never let his athletic prowess go to his head... at least not until he began his second year at college. While on his way to becoming a nationally ranked tennis player he began exhibiting a level of drive and emotional intensity that was over-the-top. His generally easy-going and accepting nature seemed to have been replaced with a streak of narcissistic arrogance. More often than not he perceived himself as superior to others... in nearly all areas. And when he felt he wasn't adequately appreciated by others he was skilled at responding with biting sarcasm. It's no surprise that after a while his friends backed away as he was no longer easy to be around. The unusual aspect of this all was that the intensity of his sharp edge was quite variable. There were times when Shawn would return to feeling more emotionally balanced and he would shift back towards the gentler characteristics that most of his friends once liked. But when his drive became intensified and his energy escalated then he'd again become consumed with arrogance and irritability.

In all three of the preceding snapshots irritability was a strong aspect of the individuals' presentation. In fact, if you weren't reading a blog on bipolar disorder you'd probably not identify the examples as reflecting an important aspect of bipolar instability. You'd more likely wonder what was going awry in the individuals' development or at least what external stressors were contributing to the dramatic shifts in mood. These are important questions to ask. Equally important, however, is the question of how we explain intense irritability when it appears as a salient feature within a broader spectrum of mood instability?

A logical choice would be to wonder about the implication of newly emerging interpersonal difficulties. Indeed, within DSMIV there's a cluster of diagnoses called "Personality Disorders" where irritability can often be a prominent symptom. But personality disorders don't just surface during late adolescence or early adulthood. They've been perking for a while. On the other hand, when we see irritability coinciding with changes in sleep, increased energy and shifts in mood that don't seem causally linked to external stressors, then it just could be that you're looking at a commonly overlooked and underestimated aspect of bipolar disorder.

One caveat to the preceding possibility: Not everyone who is irritable is bipolar. In fact, irritability will only occasionally be a prominent symptom of bipolar disorder. Just because you're irritable, you shouldn't necessarily jump on the bipolar bandwagon. However, I do advise that when irritability combines with several other symptoms typically located in the bipolar spectrum, you should definitely take notice. It just may help to illuminate a diagnosis and accompanying treatment approach that has previously remained unclear.

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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