Is It Bipolar Disorder, or Relational Oppression?

In my work as a psychiatrist, I frequently tell patients that, yes, bipolar disorder does exist and also that it’s a fad, hugely over-diagnosed and mis-diagnosed. Yes, I say, it’s true that if a psychiatrist spends fifteen minutes with a person and asks questions looking for whether a history of relevant symptoms exists, one might understandably diagnose bipolar disorder because, technically, it sounds like the diagnostic criteria have been met.

But if you sit down for a longer period of time and actually look under the hood – in other words if you actually seek to understand this person and what they have endured, the emerging clinical picture can look very different. Quite commonly, a deeper set of questions reveals that what has been diagnosed as bipolar disorder in the past turns out to be complex PTSD, a substance- or medication-induced mood disorder, or a temporary nervous breakdown in the context of overwhelming stressors.

But there’s another diagnosis that is not uncommon and that in my experience is almost always entirely missed: a human, understandable response to narcissistic oppression, abuse, or even cultic exploitation.

Let’s take a closer look at this by examining two recent examples.

Jatav, a young man, aged 28, was admitted to our program in California with acute manic symptoms. He had been treated with a variety of mood stabilizers for years but they had mostly been completely ineffective, though that history was complicated by his frequent refusal to stay on them for long. He was grandiose and entitled after admission, and difficult to redirect. He did not want to take the lithium, no matter how much his family begged him to “just get back on the medication!”

When I sat down with him to understand what was going on, it turned out that the story he told was very different from what he had told other doctors over the years. He described how difficult it was to grow up American with Indian parents, and how imperious and demanding his father had been for years, verbally and sometimes physically abusive of both himself and his mother. He hated his father for this.

Jatav couldn’t get into med school in the US so he returned to India for med school and, while there, he realized, with shame, that his family was Dalit, from the caste of untouchables and for example historically relegated to cleaning toilets. Though this intergenerational history no doubt played a role in why his father dumped so much rage and shame on him as a child and demanded such high achievement, this new awareness only deepened Jatav’s depression and feelings of inadequacy.

Jatav and I went on to consider that he might not have bipolar disorder as much as an understandable trauma response to his abusive father and the intergenerational legacy of shame and perceived inferiority. This was a revelation to him, and pulled a curtain back on his long efforts to overcome something that felt impossibly heavy. We went on to consider that it made complete sense that he would periodically swing up into grandiosity and perceived superiority over others as a way of escaping the one-down inferiority, shame and depression that he had been handed as a child. As we spoke, the lights went on in his eyes, he felt seen and like he could understand himself for the first time. His grandiosity and mania disappeared almost completely, nearly overnight. I took him off the lithium and he continued to grow in his self-understanding and stability, as well as his commitment to learning how to bring himself up a notch with a daily, minute-by-minute practice when his self-esteem and depression were too low, and to bring himself down a notch whenever he became too grandiose and superior over others, all the while acknowledging how much a relief it could be to feel grandiose and superior rather than depressed and inferior. He embarked on a path to heal both the depression and the mania by learning to live in the middle, Terry Real’s zone of health.

I could give many other examples. For the sake of your reading-span, I’ll provide just one more story today. In this situation, Susan, a forty-one year-old physician was admitted to our program in Boston, having carried a diagnosis of bipolar disorder for twenty years but who, again, had always chafed against the constant pressure to take mood stabilizers that in her mind had never worked.

We sat down and I asked her to tell me her story. She described how she had been diagnosed with bipolar disorder at age 20 when she had her first manic break. Her mother was a prominent physician who had immediately diagnosed her and started treating her with a variety of rapidly-changing mood stabilizers, and for years had been directing her to see what in her mind were the best doctors and therapists. Typically, these referrals were preceded by a phone call where the mother described the history of bipolar symptoms, medication history, and what was clinically needed.

What she had not told her mother for years was that just prior to the first manic break she had been raped. Not that this means she didn’t have a bipolar break, but it provided important context that had never been factored into the equation. Consistent with what my co-author, Lissa Rankin MD, and I often see and discuss in Relationsick (see below), Susan was diagnosed two or three months after the rape with ovarian cysts and torsion, causing severe physical pain for years in the part of her body that had sustained such serious assault.

At the end of the evaluation, I decided that in fact Susan did not have bipolar disorder and did have complex PTSD. Again, she had a human response to overwhelming trauma. After further evaluation, we also concluded that her nervous system had been dysregulated for years, starting in young childhood, because of the pressure from a narcissistic mother who, for example, demanded that Susan go to med school and become a physician in spite of her wishes to do something more artistic and creative. Against normal clinical boundaries, it was her mother who had initially diagnosed her, prescribed medications to her for years, and directed who she should see for treatment. I decided that Susan was a survivor of narcissistic oppression, and as the scapegoat of the family, was carrying the heart of the family – what others could not bear to see or carry. The mother was historically entitled, with a history of multiple affairs, never acknowledging how her narcissistic behavior registered for others in the family, all of whom were left picking up the pieces and compensating for her entitled behavior. It was notable that Susan’s manic symptoms – her hypersensitivity – mostly occurred in the context of the family dysfunction and that she proved to be mostly quite capable of participating in a balanced way in our psychotherapies. Take her away from the dysfunctional, enmeshed family system, and she looked a whole lot more normal. Hmm…

The end result is that I tapered Susan off the mood stabilizers that she had long chafed under, and she began the hard work of coming to terms with what it was going to take to heal her trauma and take responsibility for establishing healthier boundaries with her family. It took a while for the family therapist to start seeing this, but that did eventually happen. Unfortunately, months before that, Susan had to make the difficult decision to stop family therapy because she realized that the resistance in the family to seeing her story was strong and that she was going to have a lonely course for awhile because no one in the family wanted to see what was going on through the new lens of narcissism and enmeshment instead of her bipolar disorder. It’s so much easier to prefer bipolar disorder over facing family denial and the need to make deep changes.

Now, lest I create a misunderstanding, let me be clear that bipolar disorder does exist. It’s just over-diagnosed – a lot. There are times when a combination of biological, genetic, environmental, and trauma factors coalesce to create a degree of nervous system dysregulation such that the mood variations are extreme and less dependent on relational imbalances, even at times no any longer dependent on external stressors at all.

I could tell many more stories. The important points are these, in my opinion:

1. Our medical and psychiatric systems are profoundly not trauma-informed and often miss what is going on beneath and behind the symptoms. This is a tragedy and unacceptable.
2. For many medical and psychological symptoms, it is simply true that there is a lot of mental in the physical and a lot of physical in the mental. As with Susan’s ovarian cysts and pain, it is often true that the body is telling a story long before that story rises to the level of conscious awareness. We rob patients when we only go after symptoms and fail to understand the living story that is driving the physical and mental symptoms.
3. Getting the real story changes everything. As a physician, I was taught to exclude the patient’s story in order to penetrate through to the underlying signs and symptoms of illness and make the right diagnosis. But I tell trainees that it is just as efficient, and much more illuminating and accurate, to concentrate on getting the real story. One can still ask questions about signs and symptoms along the way while getting the story. But those signs and symptoms will be understood very differently when one grasps what those signs and symptoms are really about. Not unusually, in my experience, that awareness can even change the physical or psychiatric diagnosis and be enormously cathartic and illuminating for the patient. Again, the body is a messenger, and we have a responsibility to listen to what the nervous system is trying to tell us. It records and tells the story long before we are consciously aware of what the story of our lives actually is.

Relationsick: Why Putting Yourself Last is Destroying Your Health – and How to Heal, is co-authored by Lissa Rankin MD and myself and is now available for pre-order. In it, we examine the stories that our bodies and nervous systems are telling us, and what we can do to create a life that our bodies – and we – love.

(Author’s Note: All clinical stories are composites of real patient stories, with the identifying details changed in order to protect privacy.)