How Bad Can Bipolar Disorder and Coexisting Conditions Get?

“...mania is not a luxury one can easily afford.” — Kay Redfield Jamison, An Unquiet Mind

A patient once told me that the experience of having a manic episode is akin to being in the throes of addiction. She said she feels lifted when hypomanic to the point where she wants to push herself over the edge into a full-blown manic state.

You may be surprised and alarmed by manic or intoxicated behavior. The person who has fallen into this state, however, is not in their own control. My experience with such patients has prompted me to reflect on the strong relationship between substance use and bipolar disorder.

Consider that nearly all substances of abuse offer two main psychological effects: euphoria or calming and soothing and disconnection from reality. For those who are going into mania or depression, both qualities may serve as an accelerator for a destructive storm.

Some substances, particularly alcohol (via GABAergic neuronal inhibition) and cocaine (via dopaminergic neuronal stimulation), can ignite the underlying biological issues that are driving bipolar disorder. Substance use can be viewed by a patient as a coping mechanism that aims to solve psychological issues. In fact, it may exacerbate the biological issues leading to bipolar disorder.

It is not surprising that psychosocial treatments for bipolar disorder, particularly in those who experience frequent mania, are modeled after successful addiction treatment programs. Even our clinical designations for both disorders are similar: response, remission, and relapse. Among several goals of treatment, it is important to recognize emotional triggers for relapse and build a tight, supportive network that can be protective against a manic episode during stress.

Each patient’s story adds layers of complexity to treatment. What if the person has had a history of abuse or neglect in their childhood? They may have high emotional needs to self-soothe or calm themselves during uncertain situations. In these people, substances are the easiest ways to achieve emotional needs. They are also a sure-fire path to mania.

In both substance use and bipolar disorders, stigma can come from others through societal beliefs. It can come from within through shame. The fear and anguish of needing to feel loved is something we all experience. In those with bipolar disorder, the emotional experience is intensified, and the shame is much higher.

Understanding the disorders that are experienced alongside bipolar disorder is important for offering support and compassion. Healing and recovery begin when we can accept the breadth and depth of humanity and what bipolar disorder takes away from the person who suffers.