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Bipolar Disorder

Not Going with the Bipolar Flow

Acquisition of self-observing capacities for young adults with bipolar disorder

Learning NOT to go with the flow is one of the more important and painful adaptations required of most that live with bipolar disorder.

For those in their late teens and early twenties, the freedom to make their own choices as opposed to being strongly influenced by parental caution is one of the distinct markers of emerging adulthood. The first year college student feels it upon being dropped off at school and mom and dad head home. Suddenly the student isn’t living at home. There’s not the daily face-to-face interaction with parents . The first year student is suddenly independent.

But despite the geographic separation, parents are still very present within the young adult’s psyche. In fact they’re “inside” our heads for much of our lives. The freedom to make autonomous choices doesn’t just entail not having to check in with real mom or dad. It also involves being able to override internalized parental prohibitions (parental cautionary messages about what NOT to do). These cautionary messages are gradually replaced by the young adult’s own assessments of what’s acceptable and consistent with the individual’s developing lifestyle and value system. This transition is an important marker of emerging adulthood.

Think of all the times you may have thought – “My parent’s probably wouldn’t condone what I’m about to do, but I want to do it anyway.” As scary as this may sound to parents, this is an important part of college years where the late teen/young adult gets a lot more practice in making his or her own choices. Sometimes this means pushing against parental caution knowing full well that mom and dad may not approve as opposed to recurrently being influenced by the values and standards associated with parental perspective.

Such doesn't come without risk. After all, parental guidance and caution has served an important function throughout life thus far. It’s protected against (or at least has attempted to) the risks of immaturity and less-than-well-developed judgement during the first 15 to 20% of the lifecycle.

Consider the 18 to 20 year old who begins to perceive they’ve finally made it through childhood and most of late adolescence. He or she has paid the dues, been relatively compliant, done the homework, been home by curfew and has even managed to sometimes say no to risky choices when most of his or her brain has been screaming YES. Consider the anticipation, the intense desire ... to finally be able to answer to oneself instead of heeding the parental caution that has shaped life thus far. It's no small thing. This unique aspect of progression from adolescence to young adulthood is one of the more important transitions we'll experience in life.

Now imagine the dilemma of the young woman who's on the cusp of this critical stage of self-development ... and she's also just learned that her mood intensity is indicative of a chronic psychiatric illness called bipolar disorder. Most things in her life associated with normal forward progression have to be placed on hold.

A couple of hospitalizations later and after multiple assessments and discussions with psychiatric residents, attending physicians, hospital Emergency Department staff, parents, university residential life staff, athletic coaches ... and me, she sits in my office in tears. I ask ... "over the past several weeks, what's been the hardest piece to swallow? Her response - "realizing that what feels good isn't necessarily good for me ... and having to tell myself that I just can't go with the flow. In fact doing so can be the worst choice I can make."

What’s fascinating here is that she wasn't necessarily crushed by the bipolar diagnosis, or even by the likelihood of needing to take mood-stabilizing medications. No, it was the need to become highly skilled at self-observing and to apply appropriate inhibitory control during moments when her mood intensity represented heightened risk of poor judgment. Essentially she was saying ... I'm only 18. I'm not ready to try to be 42!

It was also the first moment throughout her three-month, two hospitalization ordeal that she let herself openly cry. The multiple losses accompanying the illness finally broke through. I sat with her and said, "It's OK to cry about this. You're really hurting. You're experiencing the painful loss of living a normal life and there's nothing wrong with allowing yourself to have those feelings." She was definitely hurting, but she also looked relieved at having permission to experience what she was feeling.

One of the more important skills required of the individual adjusting to life with bipolar disorder, is the capacity to accurately self-observe and determine whether what's happening is situationally appropriate or whether it's indicative of bipolar mood instability. Call it mindfulness, self-awareness, observing ego, vigilance, self-reflection, introspection, self-scrutiny, etc. It's all part of becoming increasingly aware of emerging mood patterns, and more specifically, of the subtle nuances associated with mood elevation, which is a salient defining aspect of bipolar disorder. Its presence catapults the late teen or young adult towards a degree of maturity that he or she may not feel ready to embrace. And once he/she becomes clear about the importance of this, there’s the recognition that some of the experience of being young and carefree, has to be circumvented in order to become more accomplished at managing the risks associated with living with bipolar disorder.

Depression is a fairly common experience. In fact about 7 to 9% or about one in every 11 people experience clinical depression at some point in their life. Sometimes life just hurts. We shut down, we withdraw interpersonally, become introspective, unmotivated, pessimistic, sad and possibly hopeless about feeling much better. Again, this is a fairly normal yet transient aspect of our human experience.

The flip side of the emotional pain is mood elevation. In its mild form, it's what we all strive for - good mood, happiness, "feeling up" and feeling good about ourselves. Nothing wrong with any of that.

Now let's consider mood elevation on a 10 point scale where 0 = mid-range mood - no up or down. +2 to +3 is where most of us want to visit. In fact, it wouldn't be a bad place to live much of the time, as long as we also had the capacity to dip downwards when life took us in that direction.

However, for the individual who experiences hypomanic episodes (bipolar II) or even full manic episodes (bipolar I), the +3 of mood elevation is often a point they're passing through on their way towards more intense elevation (+5 and higher), which then places them in the realms of hypomania and mania.

The whole picture of elevation involves euphoria, racing thought, rapid speech, elevated energy, elevated libido, impulsivity with impaired judgement, lessened need for sleep, grandiose perceptions of self, interpersonal gregariousness, etc., etc. It certainly doesn't all feel bad, at least not on the front end of the experience. Most of us would welcome some euphoria from time to time.

But the problem is that the individual with bipolar disorder can't be selective about the elevated mood symptoms he or she will have, or decide in advance how strong the elevation will become or even how long it will last. In fact, the hypomanic experience usually carries more detrimental consequences than pleasurable ones. Positive mood often transitions to irritability. Inadequate sleep begins to have adverse impact upon overall functionality. Hypomanic or manic thinking can become increasingly disorganized the longer it continues. Impaired judgement sometimes has people do stupid things with negative outcomes. And even if, on the whole, the elevated mood experience isn't that derailing... there's almost always the depressive crash that follows. It can last weeks ... sometimes even months. And that definitely does take a toll.

My point is that the "upness" that comes with hypomania may transiently feel good, but it rarely is good for the person. This perspective takes time for the young adult to develop. It may even require a hospitalization or two before one begins to recognize hypomania as dangerous and not something to play with.

When I'm working with bipolar young adults I often encourage them to write about their experience of mood elevation. I urge them to talk about it in a support group. I ask them to really take notice of what their "up experience" is like. I want them to be able to grasp the phenomenology of the experience - to know it from the inside - and to spot it the next time it comes around.

Why is this a big deal? So they can notice their mood changes early enough that they still have time to slow things down before the gentle flow of experience transforms into a rushing torrent of destructive mood. Typically this is achieved by lessening stimulation and excitement, increasing sleep, and utilizing medication to help slow things down.

But it's not easy. It literally means shifting from pleasurable anticipation to moderate caution. And this means not going with the flow, not embracing spontaneity and certainly not making choices that enable further disinhibition.

This self-observing capacity... this role of becoming ones own lifeguard and protecting oneself from the strong currents of mood elevation ... is one of the more painful aspects of adjusting to life with bipolar disorder. It represents a degree of caution and maturation that most young adults aren’t ready for. They certainly don’t want to have to work at it. They don’t want to have to alter lifestyle choices. They’d much rather be the competent swimmer who can manage strong currents without any concern about safety or stability. The young adult with bipolar disorder doesn't develop stable mood without also having to experience the loss of some very precious aspects of being carefree.

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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA ( www.RussFederman.com ). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com

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