It was difficult to reconcile that the mild-mannered young man sitting across from me, neatly dressed and quietly spoken with downcast eyes, had just weeks earlier been in the grips of a severe manic episode.
Charlie*, 23, had been diagnosed with bipolar disorder after experiencing mania, followed by a bout of extreme depression. Charlie had always been the life of the party and revelled in his creativity and extroverted personality, but increasingly volatile behaviour had raised the concern of his family and friends. Charlie’s chatty nature later gave way to insensitive and crude comments, together with both online and in-person self-revelatory and self-aggrandising diatribes. His speech was faster and louder than usual, he would perseverate during conversations, and jokes became increasingly risque. He had little appetite and subsisted on a few hours of sleep. Risk-taking behaviour resulted in thousands of dollars’ worth of speeding and parking fines. He spent equally large amounts on gambling, cash donations to strangers and online shopping.
But what goes up must come down. Following the month-long manic episode, Charlie slumped into a period of severe depression. His low mood was compounded as the reality of his behaviour and its consequences slowly dawned on him. Charlie felt ashamed and embarrassed. He was particularly mortified by the hazy recollections of hostile interactions with family and friends.
With time and medication, Charlie’s mood stabilised. By our first session, he had spent several weeks dwelling on the manic episode and its aftermath. Such was the dominance of shame and embarrassment in his thoughts that he preferred to present a written list of his “indiscretions” rather than speak them aloud.
Charlie expressed two main concerns: that the damage to his relationships with friends and family was irreparable, and that he would experience another manic episode.
First, we sought to understand his experience of bipolar disorder. This included information and education about the episodic pattern of bipolar disorder and the cyclical nature of mania and depression. Later, we explored factors that likely contributed to Charlie’s first manic episode, including genetic predisposition, lifestyle factors, substance use and stress.
Rather than a single condition, bipolar refers to a group of mood disorders in which individuals experience both manic and depressive episodes. Bipolar 1 is typified by extreme swings between high and low moods (mania and depression). Bipolar 2 features shorter periods of hypomania (a less severe form of mania) and longer episodes of depression.
A third sub-type, cyclothymia, features hypomania and less severe depression. The analogy of tides and waves on a beach was useful for Charlie to understand bipolar subtypes: the ebb and flow of high and low mood differs between individuals in terms of severity and length of episodes. Bipolar 1 is typically considered the most severe mood disorder but each can significantly impact an individual’s wellbeing and capacity to function.
In particular, understanding mania was essential in helping Charlie explore feelings of embarrassment and shame. Accepting the behaviour as symptoms of mania and acknowledging that he was not in control of his own actions during that time helped to mitigate feelings of indignity. Together, we devised a plan to speak with his family and friends about the diagnosis. Charlie identified that it was important for him to offer an explanation for his behaviour. Several family members and friends were initially upset and confused by interactions with Charlie during the manic episode, but were understanding of Charlie’s condition. Above all, they were encouraging of help-seeking and relieved to see his recovery.
Charlie’s worry about experiencing manic episodes in the future was well founded. Bipolar disorder is a lifelong condition; treatment aims to manage the illness and reduce its impact rather than provide a cure. Evidence suggests that men are typically diagnosed earlier than women and usually experience more frequent manic rather than depressive episodes.
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Through therapy, Charlie moved towards understanding and accepting the likelihood of future manic episodes. Together, we explored relapse prevention and harm minimisation. Medication is the frontline treatment for bipolar disorder, with ongoing compliance essential. Lifestyle considerations, such as avoiding alcohol and drugs, were helpful for Charlie to maintain stable mood. Early detection of manic symptoms was also important; Charlie was able to identify initial manic symptoms of decreased appetite and reduced need for sleep. As individuals experiencing mania typically lack insight and may not notice changes to their own behaviour, Charlie spoke with his family about being alert to changes to appetite and sleep.
Making sense of his bipolar diagnosis was an ongoing process for Charlie. Accepting the lifelong nature of his condition and the necessary changes to his lifestyle was difficult. With the support of family and friends and regular psychiatric and psychological care, Charlie was determined to maintain a fulfilling and meaningful life, and not be defined by his illness.
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*All clients are fictional amalgams
In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, call or text Mental Health America at 988 or chat 988lifeline.org.
