The news seems overly-focused on the antics of actor Charlie Sheen, who has been described by some commentators as suffering from bipolar disorder and who is viewed as currently in a state of mania. Because I have never met Sheen, I am not in a position to diagnosis him -- nor are the other commentators. But if he is truly bipolar, the prognosis is not good, unless he comes to terms with the illness and gets the appropriate medication.
Bipolar disorder is a life-long mood illness, often with the first onset during late adolescence or early adulthood. An essential element of bipolar disorder is that the individual has had at least one episode of "mania" (that is not due to a drug reaction -- such as the use of cocaine). When someone is manic, they often have a decreased need for sleep (they can feel energized on two hours of sleep), they talk rapidly, their ideas fly from one thought to another, they think they are magnificent, they can have increased sexual activity, overspending, and risk-taking activity and they can be irritable, hostile or violent. A significant number of people who are manic have paranoid ideas, believing that others are out to get them or that others are trying to block them from getting what they want to get. Manic individuals often have grandiose schemes or activities, sometimes presenting a list of "exciting projects" which often reflect little awareness of their own limitations. Manic individuals often lack any insight into their behavior -- either not being aware of how they appear to others or not caring. Sometimes they have difficulty recalling their behavior, not realizing that they had acted in bizarre and inappropriate ways. As a result, the therapist often will seek out the assistance of family members to gain a more accurate picture of the history of mania. Manic individuals are poor historians about their own behavior.
In my own writing on this topic I have tried to identify how manic people think about making decisions -- since the decisions they make can often be devastating. As I indicated, manic individuals take excessive risk in spending, investing, sexual activity, driving behavior, social interactions, often expressing bizarre and offensive opinions, engaging in aggressive and violent behavior toward others, or making other "risky" decisions. What accounts for this? Obviously, the primary cause is the biological component of bipolar disorder which is why these patients need to be on a mood stabilizer (such as lithium or an anti-convulsant -- or, in some cases, an anti-psychotic medication). However, there is an internal "logic" to manic thinking and this is what I want to describe here.
Why would they engage in such risky behavior? People who are manic often believe that they have unlimited resources and abilities -- they can afford anything or that they can accomplish anything. Thus, taking on a risky behavior seems less risky. They also believe that they can absorb any downside -- so, if their marriage fails or they lose the money in their investment, they believe that they will bounce back easily. Manic individuals have a sense of urgency -- that they need to make a decision right now so that they don't miss the opportunity that sits in front of them. They seem to speed through the day, one activity after another, trying to get as much done as they possibly can.
Manic individuals believe that they can predict the future accurately -- and that it will be filled with boundless rewards for them. Since they believe that they have the genius that others lack, they easily dismiss the opinions of others who are sometimes viewed as inferior people who are trying to block the endless opportunities that are available. Manic individuals believe that whatever they attain will be extremely enjoyable -- that they will have incredible pleasure from what they achieve -- so they are willing to take the risks to pursue those gains. In short, manic individuals are risk lovers -- they believe that taking risks is exciting, a sign of their special abilities and the means of greater fulfillment. Since they believe that they have these special abilities they become agitated when others try to dissuade them and they view medication as dampening their creativity and incredible genius. Each positive experience magnifies the desire for more positives as they "ascend" higher into a manic episode.
Sadly, bipolar disorder can have devastating effects on family, fortune, friends and future life. Most manias crash into depressive episodes -- sometimes with a high risk of suicide. Marriages end, jobs are lost, people are injured in accidents. Watching someone like Charlie Sheen -- who has been labeled by some as bipolar -- is not amusing to me. Regardless of the obnoxious comments that he displays, he is still a human being. Laughing at mental illness is a sad reflection of our lack of understanding of its devastating effects. People crash from manias and they and their families and those who love them may feel left alone to pick up the pieces. Think of Mr. Sheen's children.
The important point to keep in mind is that coming to terms with the illness is the most important step to take. Following this, involving family members as part of the treatment team can help the patient and therapist identify the beginning signs of mania (for example, lack of need for sleep, talking rapidly, risky behavior, irritability), thereby helping the physician prescribe the appropriate medication. Staying on a mood stabilizer is essential. Some manic individuals believe that "Now that I feel better I don't need the medication." Wrong. Staying on the medication will decrease the risk of the dangerous (although "enjoyable") ascent into mania or the devastating descent into depression. Psychotherapy -- such as family therapy, cognitive-behavioral therapy and interpersonal psychotherapy -- can help patients and their families cope. The outcome -- and life-course -- is not necessarily bad -- although some patients, regardless of medications, will have break-through episodes of depression and mania. Taking the illness seriously is the key. Laughing at Mr. Sheen is like laughing at someone who has been badly mangled in an accident. This is serious business. Illness is not a matter of entertainment.
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