How anosognosia and impaired theory of mind reasoning explain certain aspects of manic behavior.
“I have become fundamentally and deeply skeptical that anyone who does not have this illness can truly understand it. And, ultimately, it is probably unreasonable to expect the kind of acceptance of it that one so desperately desires. Once a restless or frayed mood has turned to anger, or violence, or psychosis, Richard, like most, finds it very difficult to see it as illness, rather than being willful, angry, irrational or simply tiresome.”
This is a quote from a book written by Kay Redfield Jamison called: An Unquiet Mind: A Memoir of Moods and Madness, (1) in which she shares how she experiences having and dealing with bipolar 1 disorder.
Bipolar 1 disorder (BP-1) can be diagnosed when a person fluctuates between episodes of mania and major depressive episodes. Symptoms of a manic episode include, for instance, having excessive energy with a diminished need for sleep, being talkative and highly distractible, and displaying behavior that can lead to significant adverse physical, relational, or financial consequences. While this list accurately describes the symptoms used to diagnose the illness, the manifestation and consequences of the illness can differ significantly from one individual to the next.
To explain the backstory of the quote at the beginning of this article, I am going to focus on the manic side of BP-1, and discuss why this illness makes it so difficult for people around a bipolar person, especially a partner, to cope with the behavior of their loved one.
In addition to being diagnosed with BP-1, Jamison is an American clinical psychologist who specialized in mood disorders. She has an amazing track record and is a leading expert in her field. Jamison has credited Robert Lowell, an American poet who suffered from BP-1, as having said
“Depression is an illness for yourself and mania for your friends.”
Due to its manic features, BP-1 is an externalizing disorder, which means that the maladaptive behaviors are directed toward the person’s environment. Partners of those who suffer from BP-1 are generally heavily impacted by the illness of their loved one during episodes of major depression, and especially during manic episodes.
Fascinatingly, while Jamison found her calling in psychology, with a strong interest in mood disorders, she was diagnosed with bipolar 1 disorder when she was three months into her first job as an assistant professor at the department of psychiatry, while the onset of her illness came ten years earlier.
“How is this possible?” you might ask. Even with optimal assessment practices, misdiagnosis of bipolar disorder is common. Its complexity makes it difficult to consistently diagnose the disorder over the long-term, due to the numerous symptoms that it shares with a range of other psychological disorders such as major depression, schizophrenia, generalized anxiety disorder, borderline personality disorder and ADHD.
Another major impediment to the diagnosis of bipolar disorder is the person’s lack of insight into their own illness. This lack of awareness is referred to in the medical field as anosognosia. It is often found, to some extent (or to a greater extent), in people who suffer from bipolar disorder. It impacts about 50% of people who have the illness.
Anosognosia should not be equated with denial, a subconscious psychological mechanism we all use occasionally. It can, however, go hand in hand with denial. A person can have an inkling that something is wrong with them, but not want to face the truth out of fear or shame. That’s a clear-cut example of denial rather than anosognosia. The two can, however, strengthen one another to the extent that afflicted people truly believe that they are just going through a phase of heightened energy and that their maladaptive externalized behavior was incited by their social environment. Anosognosia is observed not only during manic episodes but also during major depression. It is, however, more prominent during manic episodes.
The mental “blindness” that accompanies bipolar disorder extends beyond a lack of insight into one’s own illness, as it also impedes insight into one’s social interaction abilities. There is emerging evidence from research on theory of mind (ToM) reasoning — the ability to infer the mental states of oneself and others (also known as mentalization) — suggesting that mental state reasoning is impaired in someone suffering from bipolar disorder.
Additionally, research suggests that both affective theory of mind (reading emotions, feelings and moods), and cognitive theory of mind (reading beliefs, thoughts and intentions), are impaired during BP-1 episodes, particularly manic episodes.
BP-1 comes with several neurocognitive deficits that can impact, among other things, executive functioning: a cognitive ability that facilitates proficiency in adaptable thinking, planning, self-monitoring, self-control, working memory, time management and organization. Social cognition finds overlap with neurocognition, and therefore, diminished social cognition can contribute significantly to theory of mind impairment.
Some studies have indicated that impaired theory of mind abilities might be trait-related and not just state-related. Put another way, for someone suffering from bipolar disorder, the ability to accurately infer mental states can be impaired, even outside the context of a manic episode. If this is the case, theory of mind impairment might be a “phenotypic risk marker” (observable characteristic) of bipolar disorder. The jury is still out on this issue, however. (2)
The theory of mind deficiencies that accompany bipolar disorder can explain, to a certain extent, how an otherwise loving and understanding partner can be unable to see that they have been reduced to an overwhelming, at times insulting, intrusive and aggressive version of themselves due to their illness.
In fact, they are unable to accurately read and decode the reactions of others to their own behavior. Moreover, they often assume negative intent from the neutral behavior of others.
The consequences of the anosognosia and theory of mind deficiencies that often accompany bipolar disorder can be dire. People who suffer from bipolar disorder may, for instance, refuse to seek medical and psychological help, demonstrate poor treatment adherence, experience functional disability at school or work, and in extreme cases, even suffer homelessness, incarceration or early mortality due to their risky and aggressive behavior, and high risk of suicide.
Understanding these impairments can help partners, family members and friends to remain mindful of the causal relationship between their loved one’s illness and their behavior, rather than taking their behavior personally. This is no easy task, however, as maintaining a stance of understanding toward a loved one during a manic episode can be extremely difficult. At times, you may feel totally depleted and out of patience due to their relentless energy level and rude, hurtful, and sometimes even abusive behavior.
The “Richard” referred to in Jamison’s quote at the beginning of this article was her husband, Richard Wyatt. Wyatt was a clinician, neuroscientist, educator and mentor to a generation of current leaders in the study and treatment of schizophrenia.
Whenever his wife was going through a manic phase, even Wyatt, a trained expert in the field, and being fully aware of his wife’s diagnosis, found it difficult to maintain the objective stance that her behavior was the consequence of an illness, and not a personal assault on him.
For partners of people who suffer from bipolar 1 disorder, helping a loved one during a full-blown manic episode can feel like being in a game show, with unanticipated challenges constantly being hurled in your general direction. The following fictional account is based on real-life experiences of people who know what it’s like to live with a partner who is suffering from BP-1:
When you are first confronted with a manic episode of your partner, and you have no prior knowledge of the fact that she suffers from BP-1, or of how a manic episode manifests itself, you start to wonder how it can be that this person whom you know so well, who is normally a homebody, is now constantly out and about, visiting friends, meeting new people and inviting the whole neighborhood to go on a pub crawl. You find yourself getting into more and more arguments with your partner, while you always used to get along so well. You ask yourself why you are being blamed for things that were outside of your control.
Some days you have to contend with total strangers that your partner has invited to your house to counsel on psychological issues, or maybe on how they can improve the marketing side of their business. You might even run into a new business associate of your partner who is going to sell a revolutionary type of appliance that your partner has promised to invent. At the same time, in contrast to your partner’s apparent need for fun and exciting social activities, you are taken aback by the rude, offensive and intrusive behavior that she displays toward you and others.
You notice that your partner’s speech has turned into a constant stream of free association, her voice sounds hoarse from all the talking, her clothing style is more eccentric than usual, and her handwriting style is suddenly so large that even a short message takes up all of the space on a sheet of printing paper.
You have a hard time communicating with your partner as your voice is drowned out by the loud music that she is constantly playing. You find your partner sleeping in the guestroom during the few hours she is able to sleep. Hugging and caressing are no longer appreciated, with intimacy being replaced by utterings of obscene sexual allusions. Things constantly go missing, even big things like a pickup truck, or they get broken. As if that weren’t enough already, you suddenly find the offspring of a prize-winning racehorse in your garden.
Due to the significant changes in the character of your partner, you begin to wonder whether she is experiencing an acute onset of paranoid personality disorder, narcissism, borderline personality disorder, ADHD, or could it be a brain tumor? You ask yourself whether it is possible for a person to rapidly cycle through all of these different psychological disorders in a single day!
You start surfing the world wide web for information and answers, you talk to your family doctor or a psychologist, and you start to understand that your partner might be in the middle of a full-blown manic episode. This realization gives you some guidance as to where to find medical assistance and support. Often you will discover, however, that you can do little to help, because your partner sees you and other people as blameworthy for the disagreements and other challenges that pop up left and right. Your partner perceives her own behavior as nothing more than a surplus of energy, and believes that most people around her (other than you) seem to enjoy it.
You realize that you will need to wait until the manic episode has waned before you can have a quiet, private conversation with your partner, and agree on any subsequent actions to be taken.
In the meantime, you end up exhausted, burned out, frustrated, scared and feeling alone. You understand that at this point, the only thing you can do is damage control: safeguarding your partner from self-harm, harming you, harming relationships with family and friends, and damaging property, all while keeping her from depleting your joint bank account.
Once the manic episode has subsided, you find out that your partner still doesn’t share your perspective on what is going on with her, and she doesn’t see a need to talk to a mental health care professional.
A manic episode can manifest itself in different ways depending on the person and the circumstances. What can you do for your partner and yourself to better cope with a manic episode?
It is of critical importance to encourage your partner to seek professional help. If possible, accompany your loved one to medical consultations, as bipolar disorder is commonly misdiagnosed. Keep in mind that anosognosia may inhibit your loved one’s ability to provide the information required by the physician to make a correct diagnosis.
Once a manic episode has subsided, it is important to talk with your loved one about what has happened without getting frustrated, particularly if you learn that they still have no insight into their illness. They will also have forgotten situations and conversations. During a manic episode memory faculties don’t work well. Sharing the manner in which you personally experienced the episode can slowly instill awareness in your loved one. If possible, discuss different ways to deal with a next manic episode, or to deal with the depressive episode that might follow.
Write down and discuss together with your loved one the sort of behavior that might point toward signs of an impending manic or depressive episode so that both of you can nip it in the bud, or at least formulate a response plan. Warning signs can include: sleep disturbances, increased (manic episodes) or decreased (depressive episodes) physical activities and social interactions, changes in emotional behavior, disordered personal space or altered appearance, etc.
Make lifestyle changes together that facilitate well-balanced energy levels such as prioritizing sleep, eating healthy food, refraining from using alcohol and drugs, committing to an exercise routine, building in enough moments of serenity, and exercising meditation skills to manage stress levels.
During a manic episode take measures to protect your loved one from harm, including financial harm. More importantly, however, because bipolar disorder is associated with an increase in unhealthy and self-harming behaviors such as drug abuse, excessive alcohol consumption, and death by suicide, encourage them to seek professional help, and remind them to take their medication. Don’t be afraid to seek the assistance of medical or other crisis intervention professionals if circumstances warrant.
Even though you don’t feel respected by your loved one, stay respectful toward them and don’t make remarks such as “calm down,” “are you ‘hangry,’” or “are you drunk?” Don’t make the person feel stupid or embarrassed for rambling on, or for not making sense. Understand that the person is unable to apply much control over themselves, psychologically or physically. Your loved one lives in a confusing world during an episode which can make them very anxious at times.
Don’t take things personally if your loved one becomes distant or says hurtful things. Remember that their ability for theory of mind reasoning is impaired which makes them perceive the actions of others as negative. They often think that everybody around them dislikes them and view the behavior of others from that assumption. If you get offended, try to just brush it off rather than risking the exchange of more hurtful words by pointing out that you feel hurt. Tell them you love them repeatedly. If possible, try to remove the interaction to a calm and safe environment.
Don’t force the person to stay, to go anywhere, or to be with you. Give them ample space to allow them to deal with their overexcited energy in the way they want to. Don’t let them out of your sight, however, if you think they might hurt themselves, hurt others, or damage something. In extreme cases, for instance when the person is psychotic, you may need to call for medical (or other) assistance, particularly if things are getting out of hand, or if you feel seriously threatened.
Don’t push the person away when they want your company. On the contrary, listen to them, do things with them that are fun, but stick to the low energy kind of fun.
Encourage their behavior (within reason) when they are sharing their grand plans and ideas, but also invite them, with patience and understanding, to consider why their plans might fail.
Try to manage your shared social relationships, as best you can, so that both of you maintain your much-needed social network. Unless necessary, don’t disclose your loved one’s illness, as it is up to them to decide who should know about it. This can be challenging, however, due to the effects of anosognosia and impaired theory of mind abilities. At times, you may need to help others understand the uncharacteristic behavior of your loved one by disclosing the nature and behavioral consequences of their illness. Helping others to see your loved one’s behavior through the lens of their disorder can reduce stress, anxiety and anger, and mitigate damage to social connections.
Finally, yet every bit as important, take care of yourself during your loved one’s manic episode. Set boundaries, and do your utmost to enforce them, however challenging it may be. Make sure you have friends and family members to fall back on. Find ways to maintain a well-balanced energy level. If possible, from a personal and professional standpoint, try to maintain a flexible schedule. Keep your family doctor in the loop, and find a psychologist or someone who understands what you are going through to help you deal with the situation. Inform and educate friends and family members who are already familiar with your situation so that they know what to expect.
I know, a lot is asked of those who are dealing with a loved one who suffers from bipolar disorder. Depending on the course or severity of the illness, it can quickly become more than you can handle. In many cases, however, the wonderfulness of your loved one will once again shine through, and you can both explore new ways to deal with their bipolar disorder together.
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