Bipolar Disorder is a two-edged sword: A qualitative study to understand the positive edge

Abstract

Background

Bipolar Disorder (BD) can have highly detrimental effects on the lives of people with the diagnosis and those who care about them. However, growing evidence suggests that aspects of bipolar experiences are also highly valued by some people.

Method

We aimed to understand how participants with a diagnosis of BD made sense of what they took to be positive about their bipolar experiences. Interpretative Phenomenological Analysis was used in the collection and analysis of data from 10 individuals in the UK.

Results

Positive aspects were numerous, highly valued and participants welcomed the opportunity to discuss them. Three important themes emerged: 1) Direct positive impact of bipolar experiences on everyday life including amplification of internal states, enhanced abilities and more intense human connectedness; 2) Lucky to be bipolar – the sense of having been given a special gift; 3) Relationship between the self and bipolar experiences.

Limitations

Given the small size, further research is needed to explore how widely positive aspects of BD are experienced.

Conclusions

These themes highlight the need to invite people to talk about the positive aspects of their bipolar experiences as well as the difficulties they face. This may help us to understand ambivalence to current treatment and to develop interventions that minimise the negative impacts, whilst recognising and potentially retaining some of the positives.

Introduction

“I have often asked myself whether given the choice, I would choose to have manic depressive illness…..strangely enough I think I would” (Jamison, 1996, pp 217–218)

Bipolar Disorder (BD) is generally seen as a severe and enduring mental illness with serious negative consequences for the individual and their friends and family (Calabrese, 2003, Hirschfeld et al., 2003). Long-term unemployment rates are high (Dickerson et al., 2004), relationships are marred by high levels of family burden (Perlick et al., 2007) and quality of life is often poor (Michalak et al., 2005). High rates of substance misuse are reported (Weiss et al., 2007) and suicide rates are twenty times that of the general population (Tondo et al., 2003). The impact of BD is estimated to cost the UK £5.2billion per year (McCrone et al., 2008).

However, since the first description of manic depressive illness by Kraepelin (1921), the positive aspects of these experiences have been noted. Kraepelin proposed that “the disease may under certain circumstances set free powers which otherwise are constrained by all kinds of inhibition” (Kraepelin, 1921 p17). Despite this, clinical assessment tools and academic research have focused almost exclusively on the negative aspects of bipolar. This is a problem for 2 key reasons.

Firstly, focusing only on negative aspects paints a biased picture that perpetuates the view of bipolar as a wholly negative experience. Long-term follow-up studies are often conducted with people recruited via mental health services and therefore findings are biased towards describing outcome only for those people who remain engaged with services. This is only a subsample of people who meet criteria for BD and is likely to consist of those with the poorest outcomes and requiring the most support (Frye et al., 2005). Consequently, clinicians working in this area develop an experiential understanding of BD through contact only with people who are significantly impaired by their experiences. Subsequently, when giving a diagnosis, the picture presented by these clinicians is informed by biased research evidence and by their own biased clinical experiences. This picture is generally one of long-term disability, the need to avoid stress and the prospect of daily medication with severe side effects. Given the strength of the self-fulfilling prophecy (Merton, 1948), it is reasonable to expect that painting this picture will itself trigger emotional and behavioural responses in the individual receiving the diagnosis, which may lead to reduced levels of functioning and poorer quality of life (Lovejoy, 1982).

The second problem is failure to understand ambivalence towards treatment. Although there is a range of biological and psychological interventions available with proven efficacy in reducing relapse and improving outcome (NICE, 2006, Scott et al., 2007), there are high levels of non-adherence and poor engagement with services (Lingam and Scott, 2002). This phenomenon is generally understood in clinical settings in terms of “lack of insight” (e.g. Copeland et al., 2008, Trauer and Sacks, 2000), comorbid drug or alcohol abuse (e.g. Keck et al., 1997) and “personality disorder” (e.g. Colom et al., 2000). However, it may be that in understanding the positive aspects of bipolar we can better understand ambivalence towards engaging with services, as an entirely predictable and rational response. In order to test this, we first need to comprehend the full range of bipolar experiences – positive as well as negative.

There is a growing ‘popular literature’ which tells us in great detail about the positive aspects of bipolar experience. Book titles such as ‘The Bipolar Advantage’ (Wootton, 2005), ‘The Hypomanic Edge’ (Gartner, 2005), ‘Touched with Fire’ (Jamison, 1996) and ‘Bipolar Breakthrough’(Fieve, 2006) reflect the way in which this literature, written by people with personal experience of the disorder and highly experienced clinicians, presents aspects of bipolar experiences often ignored in more academic literature. US psychiatrist Gartner (2005) discusses ‘grandiose types’ whose unusual energy, creativity and enthusiasm result in ‘spectacular entrepreneurial zeal’ and ‘drive for innovation.’ In ‘Bipolar Expeditions’, Martin (2007) argues that people with BD are ‘the kind of person who is highly desirable in corporate America: adaptive, scanning the environment, continuously changing in innovative ways’ (p 216). The personal value of bipolar experiences was demonstrated in a British Broadcasting Corporation (BBC) documentary (UK) in which a highly biased sample of high achievers and celebrities with bipolar diagnoses were asked, ‘If there were a button you could press which would take away your bipolar disorder, would you press it?’ No one said yes (Wilson, 2006). Slightly more representative (though still self-selecting) was a survey of 3330 adults with BD, from which only 54% said that they definitely would push a hypothetical button which would eradicate their illness (Equilibrium: The Bipolar Foundation, 2008).

Positive aspects of BD have been the focus of academic research. Jamison et al. (1980) showed that people were able to identify short- and long-term positive effects of their mood experiences in areas of sensitivity and alertness, productivity, social outgoingness, sexual enjoyment, and creativity. She also reported that levels of manic or hypomanic symptoms are overrepresented in people defined by high levels of creative achievement, such as writers and artists (Jamison, 1989). More recently Murray & Johnson (2010) have addressed this question from the alternative perspective, looking for evidence of elevated levels of creativity and accomplishment in people with mania. They suggest that hypomanic experiences are associated with more creative, occupational and educational attainments, but that episodes of full-blown mania interfere with this process. A recent review of the literature in this area (Galvez et al., 2011) suggests support for enhanced levels of spirituality, empathy, creativity, realism and resilience in BD.

A key limitation of current research is that experiences have been evaluated along dimensions prescribed by researchers. Consequently, they may miss positive aspects of bipolar experiences that are valued by service users. A qualitative approach that explores people's experiences more openly would overcome this problem and explore the full range of positive experiences. Michalak et al. (2006) used such an approach in their study of the impact of BD on quality of life. Although mainly identifying negative impacts, some participants described how bipolar experiences had opened up new opportunities for them by positively changing their career paths or social networks.

In this study we invited people with a diagnosis of BD to tell us about the positive aspects of their bipolar experiences. We used their responses to help us understand the varied and often ambivalent relationship people have with this condition, and to consider the implications of this for clinical interventions.