Social anxiety and panic states appear to be most specifically associated with bipolar disorder.7 Because these types of anxiety entail excessive fearful responses, psychotherapeutic techniques including extinction approaches can be helpful.
Depression in bipolar disorder tends to manifest as slowed motor and cognitive function, which is likely to be evident in work situations. Additionally, loss of social interests—one of the most common and severe aspects of depression in bipolar disorders—is likely to be evident to coworkers and to negatively impact work effectiveness.
Irritability occurs most frequently in mixed bipolar states but also is characteristic of—though generally less intense in—depressed and manic clinical states. Even when strictly internal and subjective, irritability can reduce an individual’s confidence and work effectiveness. Expressed irritability, from minor annoyances to explosive outbursts, can have serious employment consequences, including termination.
Manic symptoms. The impulsivity that is common in bipolar mania can interfere with work. Acting without considering consequences, taking undue risks, or reaching conclusions on inadequate information can cause problems, including physical harm to self or coworkers. Excessive talking—usually associated with internally recognized racing thoughts—can be a nuisance when mild or problematic if it interferes with customer or coworker interactions.
Hyperactivity and increased energy may be perceived as behaviors that facilitate productivity at work (Box 2).8-10 The adaptive characteristics of many hypomanic states are infrequent or absent in depressive, manic, and mixed manic clinical states, however.
Psychosis is principally associated with manic episodes, but it can be a component of any symptomatic clinical state. Delusional ideas or persecutory thoughts are rarely compatible with a work environment, in part because of potential risks to others.
Hypomanic energy on the job: Constructive or destructive?
For some purposes, bipolar disease confers social and employment advantages. Common, frequently adaptive behavioral characteristics of hypomania include:
- perseverance
- high energy
- heightened perceptual sensitivity
- exuberance and playfulness
- optimism.
Increased energy and mild degrees of hyperactivity—as well as thinking along creative, multisystem lines—can benefit work productivity, customer interactions, and work group relations. Heightened confidence and social interests can be valuable in some sales and marketing activities.
Although these attitudes and behaviors can have constructive effects, patients need to understand their limits and destructive potential. This is not a straightforward issue, as patients may not have self-awareness of some adverse consequences of characteristics such as irritability, risk taking, or inappropriate sexual advances. A phenomenon little described in clinical literature but relatively common in biographical accounts of persons with bipolar disorder is that friends or coworkers may encourage, rationalize, and take advantage of an individual’s hypomanic energy, thwarting effective interventions.
Componential treatment
Bipolar disorder’s multiple symptom domains suggest a componential approach to treatment. It may be useful to convey this concept metaphorically to the patient. When working on a jigsaw puzzle, a section that has been put together can be largely left intact and attention turned to other sections of the puzzle. Similarly, once a particular bipolar component is well managed—whether via medication, lifestyle, attitudes, or combinations of these—that symptom is likely to remain stable, barring a new insult/stressor (such as a medical condition requiring drugs that interfere with the bipolar regimen).
If mood stabilizers control risky behavior, impulsivity, and affective lability, the regimen generally will remain effective. If residual or new problems develop in another area (such as anxiety, sleep cycle, or irritability), choose drug regimens and psychoeducation approaches that are compatible with the mood-stabilizing plan. This attitude toward treatment:
- is reassuring to most patients, who come to see a new or recurring problem in one domain as not inherently a harbinger of complete relapse
- can reduce patient- or clinician-initiated deletions and additions of medications in a regimen that has been established as effective.
Autobiographical accounts of persons with bipolar disorders can be useful in educating patients about the considerations presented here. Actress Patty Duke made these observations in describing the gradual development of an effective treatment for her severe bipolar disorder:
I work at not flying off the handle…and I’m much better at it. My general medical bills dropped by $50,000 a year since my bipolar diagnosis and treatment. Until then, I was always in the hospital for some phantom illness. I was there with real symptoms born of depression. I haven’t been in the hospital since I was diagnosed.
My recovery from manic-depression has been an evolution, not a sudden miracle. For someone who spent 50% of her life screaming and yelling about something, I am now down to, say, 5%.11