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Expert Q&A

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Cana manic episode look like a tantrum?

Asked by Sharon, Clinton Township, Michigan

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My friend's 20-year-old daughter has been diagnosed as bipolar. I have seen the depressive effects, but can you tell me how someone who is having a manic episode would behave? This girl yells, screams, swears, kicks the walls, uses inappropriate language to her parents and it usually happens when she is not getting her way. It looks like a temper tantrum to me.

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Sharon,

You have done a nice job of describing how one type of manic episode looks, but in suggesting that what you see might be a temper tantrum you have also identified the challenge that faces us every time we try to give a name to psychiatric troubles. The challenge is this: God didn't create psychiatric disorders when he was naming the fish of the sea and the creatures of the land. Whether or not we can lay psychiatric suffering at the feet of God is too philosophical a question for this blog, but wherever mental illness comes from, the names we give it, the categories we use to describe it, were created by men and women, not nature.

This is simple enough to say, but the ramifications of this fact are huge and often overlooked by both the lay public and the medical world. In regards to your particular question, bipolar disorder (also known as manic depression) is nothing but a description of a certain pattern of symptoms. In the case of bipolar disorder, the pattern requires the presence of at least one manic episode and usually also includes episodes of depression. Keep in mind that because mania is only a word we use to describe certain types of behavior and emotions, there is no clear answer to your question of where mania stops and a temper tantrum begins.

However, having said all this, let me rush to affirm how useful many psychiatric diagnostic categories are. They help us understand what we are seeing, they suggest treatment options, and they tell us a lot about what is likely to happen to a person in the future. So it is of utmost importance, actually, that we try to ferret out what is most likely going on with your friend's young daughter.

Let's try to sort things out by considering two extreme cases. Let's suppose your friend's daughter was always a quiet, gentle girl who did what she was told and caused no trouble. Then a few months ago she began to radically change. Over the course of several weeks she began to become unreasonably irritable and violent. She stopped sleeping much. She randomly curses people out on the street. She throws things whenever her will is crossed. Just to make it really easy let's suppose she begins telling people that she is enraged because the spirit of Jesus when he threw the money changers out of the temple has entered her body and now controls her.

Given this scenario, every single one of us -- except the poor young woman herself -- would recognize that she is not herself, that something is very wrong, that she has an illness. She has developed bipolar disorder because she is clearly having a manic episode.

Now let's consider a very different scenario. Suppose this young woman had a difficult childhood and has never done well. From an early age she's been repeatedly in trouble, first at school, later with the authorities. She has always been moody, quick to anger and impulsive. She has very brief periods of elation when something good happens, but mostly she is unhappy and anxious. A year ago she had a full depressive episode. She is doing better now, but she is back to herself, which is to say that she is short-tempered and violent.

What do we think now? If she has always shown symptoms that could fit under the rubric of mania, should we call this mania or a really bad personality problem? In this scenario we'd probably be better served to consider her as having something like borderline personality disorder with a history of major depression. But if next year we caught her talking a thousand miles an hour about being the Virgin Mary, not sleeping and running down the street naked, we'd have to say that we were probably wrong and that the behavior we're seeing now was a preamble to full bipolar disorder, not really a personality problem. Why does it matter? Well, data suggest that women with borderline personality disorder tend to improve with age, whereas bipolar disorder tends to worsen with age.

Hopefully you can use the examples I've given to think through for yourself how best to conceive of your friend's daughter's very disturbing behavior. Whatever we call it, the biggest mistake we could make is not to try to get someone in her condition good psychiatric care. I don't need to tell you that this young woman's road through life is likely going to be disastrous if she doesn't get the help she'll need to change her emotions and behavior.

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