A rare glimpse into the bipolar life, where behavioral markers often come in 3’s.
TABLE. “The Rule of 3” hinting at soft bipolarity in a clinically depressed individual
Hollywood depictions of bipolar disorder often feel stilted, with characters that seem molded from the DSM criteria. Claire Danes changed all that in her gritty portrayal of an FBI agent with bipolar disorder in the Showtime series Homeland. Her source material? YouTube: “There was a lot of footage of people who recorded themselves when they were in manic states. I think they were probably up in the middle of the night and lonely and, you know, needed to talk.”1
The Internet can enrich our understanding of bipolar disorder as well. In his column last month, Dr. Phelps drew from the vivid texts of bloggers with hypomania.2 The Internet is also the source of a remarkable new study that recruited no fewer than 71,247 people to complete a lengthy online survey. About a quarter of them had a mood disorder; all were Brazilian. In addition to the usual psychiatric rating scales, the survey asked a host of personal questions that offer a rare glimpse into the bipolar life.3
People with bipolar disorder are active-in mind, body, and spirit. Compared with controls and those with unipolar depression, they change religions, hairstyles, and sexual partners more often. They read more books. They curse more and have more “provoked” car accidents. Their clothing is more extravagant and, even in this age of body art, they are more likely to get tattoos and piercings than those with unipolar depression and controls.
There’s a special knack for starting relationships that often goes along with bipolar disorder. This can be an asset in an otherwise rocky life. In previous research, we learned that bipolar patients have broader social networks than do those with other diagnoses.4 In the Brazilian data, they had multiple marriages (≥ 3) and multiple sexual partners (≥ 60) more often than those with unipolar depression and controls. Pathologic love was also more common among those with bipolar disorder, particularly among the women.
Pathologic love is not a symptom I could find in the DSM, but from the paper’s description it looks similar to a chief complaint I often encounter in practice: “Have you ever been so in love with or obsessed about someone that nothing else mattered to you, you felt you could not live without this person, felt bad when away from this person, and tried to monitor his/her activities?”
Prior to this research, we knew surprisingly little about the sexual lives of bipolar patients. Although couples with bipolar disorder rank sexuality as their most important marital concern,5 a 2016 review concluded that “the overwhelming majority of articles that look at couples in which one partner is bipolar exclude the topic of sexuality.”6
These new data help fill in that gap, though that wasn’t the primary aim. The authors actually set out to test a controversial hypothesis put forth by Hagop Akiskal: that behavioral markers can help distinguish bipolar and unipolar depression. In 2005, Akiskal derived the “rule of 3’s” by comparing these markers in 1000 outpatients with bipolar II disorder and unipolar depression.7 His list is also revealing (Table), and it’s significant that this unorthodox perspective can now claim validation across 2 cultures.
As colorful as these data are, it’s important to keep in mind that only a minority of bipolar patients endorsed these soft signs (5% to 30%).3 The greater world is also full of people with artistic gifts, exuberant lives, and sailor’s tongues who don’t have bipolar disorder. Soft signs of bipolarity are only useful when they occur alongside a history of cyclical depressions.7 In that context they can prompt us to gather more history, interview the relatives, and use antidepressants with caution (if at all). Should you encounter these signs outside of the office setting, you can safely put any screening questions aside and move on to what’s likely to be a lively conversation with an interesting person.
Dr. Aiken is the Director of the Mood Treatment Center and an Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He does not accept honoraria from pharmaceutical companies but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, which he coauthored with James Phelps, MD.
1. National Public Radio. Claire Danes: Playing Bipolar Is Serious Business. September 19, 2012.
2. Phelps J. A more nuanced view of hypomania. Psychiatric Times. Published February 7, 2017. Accessed March 1, 2017.
3. Lara DR, Bisol LW, Ottoni GL, et al. Validation of the “rule of three”, the “red sign” and temperament as behavioral markers of bipolar spectrum disorders in a large sample.
J Affect Disord. 2015;183:195-204.
4. Poradowska-Trzos M, Dudek D, Rogoz M, et al. Comparison of social networks of patients with unipolar and bipolar disease. Psychiatria Polska. 2007;41:665-677.
5. Frank E, Targum SD, Gershon ES, et al. A comparison of nonpatient and bipolar patient-well spouse couples. Am J Psychiatry. 1981;138:764-768.
6. Kopeykina I, Kim HJ, Khatun T, et al. Hypersexuality and couple relationships in bipolar disorder: a review. J Affect Disord. 2016;195:1-
7. Akiskal HS. Searching for behavioral indicators of bipolar II in patients presenting with major depressive episodes: the “red sign,” the “rule of three” and other biographic signs of temperamental extravagance, activation and hypomania. J Affect Disord. 2005;84:279-90.