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ANGERcoping with

BIPOLAR+

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IRRITABILITY AND OUTBURSTS OF RAGECAN BE PART AND PARCEL OF BIPOLAR,

BUT YOU CAN LEARN USEFUL STRATEGIES TO

By Denise Mann

unravel your

WRATHIT STARTS WITH A ROUTINE ANNOYANCE— the living room is a mess again, or another driver cuts you off. Irritation takes hold, then mushrooms as swiftly as a nuclear explosion. Cheeks redden, the pulse quickens, and … boom. Welcome to bipolar rage.

For Paul of Nevada, an innocuous comment by his wife during dinner could flip his switch.

“I would go off,” the 45-year-old architect says. “It got bad.”

Paul recognized that something wasn’t right with his ever-changing moods, but stigma kept him from seeking treatment for bipolar until a year or so ago. So periodically, “for the better part of 20 years, I would get irate over nothing,” he says.

Stress at work would affect his sleep, which would affect his equilibrium. He would keep it together at the office, only to take it out in harsh words at home. His three sons would make themselves scarce. His wife bore the brunt of his verbal attacks before their marriage ended.

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“It was 100 percent the reason for my divorce,” Paul says.

Irritation and anger can be a normal and even healthy response to certain provocations. As with many emotions, however, people with bipolar disorder appear to be more vulnerable to extreme responses.

“Everyone can become frustrated or angry, but loss of control can be part and parcel of bipolar disorder rage,” says Jeffrey Borenstein, MD, president and CEO of the Brain & Behavior Research Foundation.

Irritable mood is among the primary diagnostic criteria for mania and hypomania, and there’s growing understanding that anger and irritability can be hallmarks of depression as well.

Left unchecked, irritability and its downstream cousins, anger and rage, can have dramatic and devastating effects. Family life and friendships suffer. There can be severe repercussions in the workplace and, on occasion, seismic encounters with the justice system.

At the least, guilt and regret after an outburst have corrosive emotional consequences.

“For five seconds afterward, there is some relief,” Paul admits. “And then there’s the, ‘Oh my God, what did I just do?’ and the remorse would send me into a depressive state.”

Bringing bipolar mood shifts under control may lessen the pressure to blow up, but that doesn’t mean the volatile emotions will entirely evaporate. That’s where anger management techniques come in, such as counting to 10, taking deep breaths, and finding a positive outlet instead of letting the steam build.

It’s also important to learn the triggers that typically set you off and the mental and physical signs of an impending

“ EVERYONE CAN BECOME FRUSTRATED OR ANGRY, but loss of control can be part and parcel of bipolar disorder rage.”

—�Jeffrey�Borenstein,�MD,�president�and�CEO� of�the�Brain�&�Behavior� Research�Foundation

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eruption. Paul says that in the past year, he has gotten better at recognizing his warning signs.

“I feel my blood pressure start to boil and have to catch it and calm down,” he says.

HOSTILE TERRITORYLearning to tease apart appropriate emotional reactions from those associated with a mood shift—in either direction—requires insight developed over time.

“It’s important to know if your anger travels with symptoms of mania, such as not needing to sleep, or with the symptoms of depression, such as losing interest in things,” says Elizabeth Brondolo, PhD, a psychology professor at St. John’s University in New York City and co-author of Break�the�Bipolar�Cycle:�A�Day-by-Day�Guide�to�Living�with�Bipolar�Disorder.

It’s easy to detect changes when a normally easygoing person starts to get cranky. For people whose temperaments are marked by “hostile personality traits”— impatience, frustration, rudeness (such as interrupting when others are speaking)—there may be a more subtle crescendo.

A 2012 study involving more than 500 people found that those with bipolar (either type I or II) are more likely to be argumentative, feel hostile toward others, have hot tempers, and act out than those without the disorder, especially during a mood episode. There is also a greater likelihood of anger escalating quickly, resulting in sudden and explosive outbursts.

However, there may be underlying differences in disposition between people who feel “snappy” and those who feel “happy” during hypomanic and manic phases. A study in the March 15, 2015 issue of the Journal�of�Affective�Disorders found that on a temperament scale, the “snappy” group scored as more irritable, more self-focused, and less cooperative. They were also more likely to report higher levels of

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irritability during depression and to have a comorbid anxiety disorder.

Symptoms inherent in bipolar also may feed a propensity to flare up, according to Brondolo. For example, when your mind starts racing, “you are pushing your thoughts forward and may rush to catastrophic or unjust conclusions that can make you angry,” she says.

Brondolo recommends tracking various aspects of your feelings and behaviors on a regular basis —although she notes that such self-awareness isn’t easy once your brain starts misfiring.

Her checklist starts with the basics: Am I upset about something? If so, what and why?

Also consider whether you are feeling anxious, sleeping normally, drinking alcohol, experiencing symptoms of mania or depression, and taking medications as prescribed.

“The answers to these questions may motivate you to call your doctor,” she says.

If you can head off shifts into mania and depression, “related anger responses will also abate,” points out Norman Sussman, MD, a professor of psychiatry at New York University’s Langone Medical Center.

“Sleep is one of the most sensitive early markers of a shifting mood—even one night of lost sleep can be a trigger for anger,” he adds.

Early intervention—checking for medication adherence, tweaking a regimen, or visiting the therapist—may help stave off a full-blown episode, Sussman says.

The best way for couples and families to weather angry outbursts is to plan ahead, says clinicial psychologist Sarah Keedy, PhD.

“We all need a tool kit filled with healthy strategies on how to cope with moods and this is best developed in advance,” says Keedy, director of the Cognition-Emotion Neuroscience Laboratory at the University of Chicago.

Having all parties sign off on an action plan up front is essential. For example, she says, talk through what you think should happen when anger starts to get the best of you.

“Should the family member leave or should they remind you about your coping strategies? The key is to agree on what is OK in advance. This may help the situation go more smoothly, as well as mitigate guilt or other hurt feelings later for all parties.”

That conversation should include the best way to handle potentially volatile situations, such as the behaviors and circumstances that “would trigger the need for outside intervention of any kind,” Keedy says—ranging from calling the person’s medical team up to calling the police.

FAMILY PLANNING

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TIME OUTWhen emotions start to boil, you can turn down the heat by giving yourself time or space. That’s where classic advice to take three deep breaths or count to 10 comes in—anything that interrupts the anger response.

Stepping away may be even better—for both parties in the situation.

Kitty, an IT consultant in Canada, knows she needs some time by herself when she’s feeling roiled. She recalls one occasion when she was feeling “super annoyed” with everything her partner did and said.

“In my mind, I heard myself saying something horrendous that would have made her feel awful about herself. I immediately turned around and told her to give me some space,” she explains.

Kitty used her “alone time” to review some of the usual suspects.

“Did I take my meds? Yes. Did I sleep well that night? Yes. Was I depressed? Nope. Did I have a stressful day? Not really. When was my next period due ... bingo!”

She adds, “Once I was able to process all of this, I went to find [my partner], gave her a huge hug and a kiss, and began to explain what happened and discuss her feelings.”

Open and honest communication, along with better education about bipolar for all parties, makes a huge difference. Family therapy can be helpful in promoting discussion about the disorder and related issues, exploring family dynamics and communication patterns, and developing a unified response strategy.

“Families can learn about the signs of bipolar anger and work together to devise a plan about what to do to better identify and manage those symptoms when they occur,” Borenstein says.

“ Families can learn about the signs of bipolar anger and WORK TOGETHER TO DEVISE A PLAN … [to] manage those symptoms when they occur.”

—�Jeffrey�Borenstein,�MD

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That might mean walking away from a loved one when he or she is starting to get angry or removing young children from a potentially ugly scene, he says.

Recognizing that someone’s words and actions stem from a bipolar mood shift and learning not to take it personally can be hard enough for adult partners, let alone the younger members of the family. It may be helpful to have an age-appropriate discussion with children about your diagnosis.

“You can acknowledge that this is a medical condition and instead of having symptoms like rash or a fever, the symptoms of bipolar disorder are behavioral disturbances —like moodiness or exhaustion—that wax and wane,” she says. “Give kids a context so they know that you may be a little more irritable, and so they understand that this is not their fault.”

BOTH SIDES NOWSometimes the pendulum can swing too far in the other direction: Any signs of anger and irritation get dismissed as “just part of the bipolar,” even when they’re justified. That’s why developing the skills to have a calm, frank discussion focused on perceived problems, not personalities, matters so much.

That conversation isn’t likely to happen once symptomatic irritability or anger take hold, however. Years of experience

“ Give kids a context so they know that you may be a little more irritable, and so they understand that THIS IS NOT THEIR FAULT.”

—�Jeffrey�Borenstein,�MD

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have taught Anna when to try to talk to her husband and when to simply leave the room.

“Sometimes he can’t be reasoned with,” she says of her husband, Jack, a television executive from Connecticut. (The couple asked that their real names not be used.)

If Jack’s vehemence is out of proportion to the situation, Anna will leave him alone. She’s also grown familiar with the situations that tend to set him off. Although he’s much better at recognizing and defusing his anger these days, she says, she still gets tense when they’re in the car together, especially when there’s traffic.

“Bad drivers and rude people can start my clock ticking,” admits Jack, “and then I imagine all sorts of arguments with the ‘offending’ person. I can almost feel my blood pressure rise.”

Now that his bipolar is under control with medication, he usually has enough clarity to hit pause when he’s getting stirred up. That wasn’t always the case.

“I got myself into trouble before,” he admits, recalling one encounter with a fellow customer at a gas station that ended with him in police custody.

If he were to find himself facing that same inconsiderate person at that same gas station today, he says, he would walk away and talk himself down.

“You have to learn how to control your impulses and know when they are coming,” he says.

It’s a process that involves a lot of trial and error, he points out—and the results aren’t guaranteed to work every time. He and his wife are considering moving to a less stressful community to avoid some of his triggers.

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In addition to inflicting damage on relationships, rage may have devastating physiologic effects, explains Redford Williams, MD, director of the Behavioral Medicine Research Center at Duke University School of Medicine.

“Anger activates our body’s fight or flight response, which is the release of stress hormones such as adrenaline and cortisol,” says Williams, whose books include Anger Kills: Seventeen Strategies for Controlling the Hostility That Can Harm Your Health.

Over time, elevated levels of stress hormones cause wear and tear on all body systems. And when people who are irritable and easily frustrated by temperament go into anger mode, Williams says, “all components of this [anger] response occur at higher levels.”

“We know that people with a hostile personality type develop hardening of their coronary arteries at an earlier age than their less hostile counterparts,” Williams says, and that enhanced response may be why.

“Whether or not people who have anger as a component of bipolar disorder show the same exaggerated fight-flight response is not known, but anger is certainly bad for the heart and a potential contributor to the development of heart disease and high blood pressure,” he adds.

Clinical research demonstrates that cognitive behavioral stress management training can help people learn to reduce hostility and anger. Here is an exercise from the Williams LifeSkills program that goes by the mnemonic "I AM WORTH IT.”

I: Is the situation Important to you?

A: Is your anger Appropriate given the facts of the situation?

M: Is the situation Modifiable?

WORTH IT: Is taking action worth it?

If you answer “no” to any of those questions, Williams says, it’s a signal to mod-ify your reaction—for example, by reminding yourself, “Hey, this is not that import-ant!” or practicing a meditation exercise.

If the answer to each question is yes, you can take steps to target the trigger for your emotion—in a way that is proactive rather than destructive.

That would include problem-solving to change the situation or approaching the other people involved to assertively discuss how their behavior is affecting you and what you need to have happen differently.

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Other favored strategies when he feels on edge: playing some feel-good music “real loud” and hitting the gym.

“I do cardio and listen to music, and usually feel a lot better when I finish my workout,” he says.

OUNCE OF PREVENTIONKeeping a journal helped Joyce of Iowa, figure out her typical triggers.

“I write down how I am feeling so I can look back and reference other entries to look for common themes,” she says.

Journaling helped her identify behaviors to address, such as waiting calmly at traffic lights, being patient with others, and handling comments that irk her “whether aimed at me or not,” she reports.

After three decades of living with bipolar, she has a handle on the emotional and physical signals that tell her it’s time to redirect her energy. When she feels her temper heat up, she gets down to her favorite music, including disco tunes like Chic’s 1978 hit “Le Freak.”

“My therapist told me to put on my favorite music and dance when I am feeling rage. I had to laugh at the suggestion at first, but it works, and the only one who can see me is my cat.”

Working out on exercise equipment, getting in the pool, or taking a brisk jog also gives her angry feelings a positive outlet.

“Sometimes I have to push myself to do something physical to nip it,” she notes.

“Going for a hike or a walk or just changing scenery also helps me let off steam in a healthy way. If you go out and

“ SOMETIMES I HAVE TO PUSH MYSELF to do something physical to nip [my angry feelings.]”

—�Joyce�of�Idaho

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bash the windows of your apartment, you will end up with more problems than when you started.”

Preventive stress management helps head off anger and rage. There are many different approaches, and the key is to find one that works for you.

Kitty, IT consultant, says yoga has really helped her. She’s now helping others learn yoga as a way to cope with their moods through a local foundation.

Kitty wishes that she’d had better coping tools earlier in the course of her illness.

“I said horrible things to my siblings and parents that hurt them and they remember them till this day,” she says.

As she worked her way back to wellness, she says, “we’ve done much healing and growth.” And rather than beat herself up over the past, she chooses to focus on how far she’s come since then.

“No one will make you feel worse than yourself, so forgive yourself for the things you did and said to your friends and family members. [Now] I just take a few deep breaths and a fraction of a second to collect myself and remind myself that I am in charge, not the bipolar.”

Denise�Mann�is�a�freelance�writer�in�New�York�City.�Her�work�appears�regularly�on�EverydayHealth.com,�WebMD.com�and�in�Woman’s World�magazine.

“ No one will make you feel worse than yourself, so FORGIVE YOURSELF FOR THE THINGS YOU DID AND SAID to your friends and family members.”

—�Kitty,�IT�consultant

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