Can you or your therapist trigger a manic episode? 

Q: I was wondering if in your experience you have treated people who trigger manic or depressive episodes themselves? My pdoc claims that my last manic episode occurred because of some things said in session, another because he was late, etc. While I agree I am extremely sensitive, and my cycling seems to have taken on a life of it's own- is this possible? The timing was right, but I don't remember feeling unusually angry or upset- but on one hand I'm being told this is biological disorder (and I certainly have the genetics) and now it is psychologically caused. Is there a real answer here, or do I get to add a personality disorder to the list? Thank you again for your input.

Dear Judy --
That's a very important question you ask.  Here's one observation that's relevant: there are a lot of people with this "bipolar" thing, and most of them with "trauma histories", that seem to have the thinnest skin you can imagine -- i.e. interpersonally they can detect tiny nuances in "acceptance" by others, including their therapists.  In my experience they can be better than me at telling what I'm feeling about them.  They can read the slight furrow in the brow, the look away for a hundredth of a second. 

Now, what might this mean?  Well, it could be that trauma makes a person sensitive to whatever might relate to "threat" in the future, including especially how others are relating to them, especially the powerful people, as many clients can experience their therapists to be (Freud certainly had that part right; you may have heard it referred to as "transference"). 

I think this also might be a form of something else I've seen commonly: people with "bipolar" variations seem sometimes exquisitely sensitive to sensory stimuli.  It's like a migraine, where people want to be in a dark room, very quiet, and the worst stimulus of all seems to be other people.  Worse yet, crowds of them.  Or rather, worst, crowds of strangers.  It's like having a migraine of social phobia!  

Then, combine this physiologic state with cycling so rapid, so responsive to stress that the slightest additional stress triggers more cycling.  Now, wouldn't that look like "cycles", triggered by things like your therapist being late -- or rather, the being late might not be so bad, but when the therapist then wants to make a big deal out of your reaction to his lateness?  Wouldn't that make almost anybody feel nuts?  I can talk: I've done this, because I heard in my training I was supposed to make an issue out of a person's reaction if I was late.  In my opinion it's one of the most arrogant psychiatric maneuvers (we have a few more) -- even though there may well be some truth to the fact that a patient, perhaps one like you, is likely to have a reaction to our being late that goes beyond what others (i.e. people not seeing therapists, e.g.) would experience.  Namely, it stings, because they have thin skin, because they've often experienced trauma that sensitizes them to their safety with somebody like this therapist.   Anyway, you can tell this one makes me mad; this being a volunteer job I can rant a little. 

So, this rant is to say that in my book, according to the theory I just offered you, your experience does not qualify you for a "personality disorder" (another of psychiatry's more embarassing areas, this personality disorder business).  However, treatments designed for said P.D.'s might still be of value, namely Marsha Linehan's program -- but that's because they'd be good for anybody with super-thin skin.  So even if you went through such a program, if you could find one, which aint' easy despite the fact that it's the only placebo-controlled research demonstrated treatment for personality disorder (rant now almost over); that wouldn't mean you had a "personality disorder".  Point being, this is a very weak diagnostic deal, amongst our many weak diagnostic concepts. 

There.  Hope I didn't hurt you in the process; hope that helps.

Dr. Phelps

Published January, 2001