When people search for information about bipolar disorder, they usually come across descriptions of the “major” form, once known as “manic-depressive psychosis.” The term “bipolar,” however, as well as “cyclothymic,” is used to describe a range of conditions, a large part of which falls within the field of minor disorders—that is, conditions in which the person nevertheless retains the ability to understand what is happening around them and does not have gratuitous (delusional) ideas about themselves or their environment.
Minor disorders (type II, cyclothymic disorders, “dramatic” personality disorders, temperaments) nevertheless alter the kinds of actions a person takes, with consequences precisely for the surrounding environment and for “real-life” situations. The “minor” bipolar person is not alienated from reality, but precisely for this reason their “troubles” are mainly relational. This is also why some cases that begin very early (in childhood or early adolescence) and continue continuously eventually come to coincide with the person’s “personality” and are described as narcissistic, histrionic, borderline, antisocial, or passive-aggressive “personality disorders.”
If we were talking about a building, we could say that personality is the external architecture: how the building looks, how it is laid out and developed, how it appears from the inside as one walks through it and climbs its floors; whereas the “disorder” defined according to individual symptoms is comparable to the blueprint on paper, with its foundations, measurements, and load-bearing structures. Pathological “dramatic” personalities (those mentioned above) are therefore typically built upon a bipolar framework.
The usual presentation of bipolar II disorder in an outpatient setting is as follows: the person reports depression and anxiety as the issues that need to be brought to the doctor’s attention, and there is then a history of instability, turbulence, exuberance, or conflict in relationships with others (friends, partners, parents, children).
The person’s overall disposition is determined by their brain, which organizes itself from birth and expresses itself through certain underlying attitudes (temperaments), which we are accustomed to describe in terms of “mood” or “affectivity.” These are variations, general settings associated with preferences, abilities, the type of attitude and approach adopted in relationships with others, the way other people’s attitudes toward us are perceived, the ease with which one reacts or makes choices in order to obtain what one wants, and the liveliness with which one thinks, makes plans, and processes experiences.
We are accustomed to thinking, for example, that intelligence is a kind of initial “endowment,” which cannot be modified very much even though it can be trained. But mood, inclinations, introversion/extroversion, impulsivity, sensitivity to perceived slights, irritability, and rejection of imposed rules are also all aspects that have their own cerebral constitution.
The onset of a disorder changes things considerably, and usually coincides with the beginning of problems with the surrounding world, followed by failures or difficulties in managing one’s life projects.
The disorder makes the individual more rigid, regardless of whether this rigidity takes the form of exuberance, argumentativeness, or fearfulness. In every case, it is a form of rigidity. The person no longer has the flexibility to adapt to circumstances without throwing everything to one side, or to reconcile different situations within the same life.
A person in a “hypomanic” phase (that is, experiencing a lesser degree of excitation) will tend to make new choices, add experiences to their life, and do everything more intensely and more superficially, initially often with greater satisfaction, because they are in a phase of “conquest” or perhaps “re-conquest” following a previous negative period.
When reality is no longer favorable, nervousness, anger, arguments with others, and “active” frustration take over, together with an inability to decelerate and stop in order to reflect, change direction, or go back and reprogram one’s goals. Under these circumstances, the person moves into a “mixed” mood state, in which their attitudes become conflictual.
The person may appear petty, mean-spirited, focused only on what satisfies them in the moment, and argumentative toward those who do not indulge them or roll out a red carpet for them. They may envy those who are having more success, and be unable to cope with rejection except through aggression or hypersensitivity to perceived slights (narcissism).
Alternatively, there may be a tendency to provoke reactions, to “act out” painful or negative feelings in front of others in order to gain them as allies, induce guilt, or morally blackmail them. A person with these behaviors (“histrionic”) recovers their role through this “performance,” attempting to regain ground in a reality that instead sees them losing ground or failing to provide what they want.
In extreme forms, the histrionic individual may resort to pretending, lying, or slander, and in order to sustain these behaviors it is not uncommon for them to turn to substances that help them avoid embarrassment and shame and become more turbulent and dramatic in their performance.
The borderline individual will appear intolerant and unstable in the way they express love and hatred—extreme feelings—toward the same people or situations, or simply in the way they shift from a feeling of love or hatred to complete indifference. The borderline mode involves action as a mechanism of expression, so aggressive or provocative acts, self-harm or other risky behaviors, running away, and emotional involvement with people who are unknown or only superficially known will be common.
The antisocial variant involves destructive actions, gratuitously cruel behavior, or physical or psychological abuse of others, an inability to experience positive feelings except in brief episodes (but in those cases in an all-encompassing and radical way), and systematic rejection of laws and conventions, with one’s actions justified on the grounds of injustices suffered or a general contempt for everyone.
When these attitudes occur in young people who may also use alcohol or drugs, the “borderline” and “antisocial” components become much more pronounced, and therefore so does the aspect concerning actions and “material” troubles.
It is nevertheless common to observe narcissistic and histrionic forms among adults who, during periods of lesser excitation, disrupt and destroy marital equilibrium, relationships with children, working relationships, or friendships. Suddenly, people who had previously been sources of support are seen as “enemies” or as those supposedly responsible for everything that has gone wrong.
Their previous life is described as a life of dissatisfaction, constraint, a cage, a death from which they wanted to free themselves. Not infrequently, in these circumstances, it is spouses and/or children who seek advice regarding marital or family breakdowns, distressed by the suddenly “childish” and “hostile” behavior of people to whom they remain emotionally attached and with whom they share a life.
From their point of view, these are people who have “lost themselves” in romantic dreams, almost as though they had returned to adolescence, or who have embarked on unnecessarily risky initiatives at work, or who demand the kind of freedom of action that an adolescent might ask of their parents.
Conversely, the person going through these phases finds themselves caught in a kind of wheel from which they cannot seem to escape, between phases of acceleration in which they feel they can dominate their environment, and phases of collapse in which they feel they have failed or become stuck, and in which they realize that they have cut themselves off from the security they once had.
The lesser excitation of bipolar II disorder is not merely—as people often experience it during an excited phase—a way of breaking with the grayness of their previous life. It is also a state that prevents them from flowing back once their “new life” ceases to be as beautiful as it had seemed, or begins to create more problems than anything else.
In other words, excitation, even when mild, is like a clamp on the steering wheel of a car that prevents the driver from turning, parking, making a U-turn, or going back. Sooner or later, simply as a matter of probability, the environment will stop smiling even at someone who approaches it with the best of moods and enthusiasm. It is under these circumstances that the “charge” of lesser excitation (hypomania) turns into friction, into a negative, angry, restless charge, without a natural cooling-down process being able to take over.
These situations are often approached by referring to personality, as though it were a separate issue from the mood disorder (bipolar disorder). This complicates the problem instead of tracing it back to a simple underlying matrix on which to begin working: the mechanism of mood instability.
Furthermore, the person may come away with the idea that others, together with the therapist, consider them “wrong” in terms of their character, in addition to being “disordered” in terms of their mood at that particular moment.
Instead, even—and especially—“relational” choices are conditioned by mood states. Indeed, one could say that bipolar II disorder and the associated personality disorders are those that most often unfold “together” with the other protagonists of one’s life, producing collateral suffering in these situations.
Tracing these situations back to the underlying type of disorder is important in order to make use of already established treatments without, especially during the initial approach, challenging the person’s choices as such. Instead, it is more useful to help them understand how these choices can vary according to mood, and above all how mood stability makes a person freer, more flexible, and less vulnerable to illusions and disappointments.