Firsthand accounts of one of bp’s most destructive and challenging symptoms.
A few years ago, a middle-aged woman from Vancouver, British Columbia, happened to read an article about bipolar disorder and hypersexuality, written by her very own psychiatrist. In all the years she’d been going to see him, she was shocked to realize, this doctor had never once asked if hypersexuality was one of her symptoms.
“I wrote to him and said, ‘This is me,’” the woman recalls. “ ‘You never told me about this part.’”
Hypersexuality may be the last frontier in bipolar disorder. Even now, despite everything that has been learned about the illness, it’s hard to put a finger on how big a problem it really is. The research is limited. Only seven studies have ever been published on the subject and their findings diverge: According to these studies, hypersexuality occurs in 25 to 80 percent of all patients with mania. After reviewing the literature, Manic-Depressive Illness (the 2007 text by Frederick K. Goodwin, MD, and Kay Redfield Jamison, PhD) settled on an average of 57 percent.
And that hardly tells the story. For, despite its primal role in human behavior, sexuality remains one of the hardest, most sensitive subjects to dredge up in any but the most cursory details. Which explains why, while hypersexuality is listed as one of the primary symptoms of bipolar in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), many psychiatrists refer to it almost as an afterthought—if at all—when forming a diagnosis:
“Like, what do you mean?” demands Andy Behrman, who became a poster boy for bipolar disorder with the 2003 publication of his edgy, sexually frank, and popular book, Electroboy: A Memoir of Mania. “Am I having sex with strangers? Yes. Constantly masturbating? Yes. Can I get myself to a place where I’m fully satisfied sexually? No. As much as I want to shop, buy, and make money, that’s as much as I want to have sex.”
Though hypersexuality may present itself as just one aspect in a constellation of problems, it is often the most destructive and challenging part of bipolar disorder—troubling families of young children suffering from juvenile hypersexuality, ruining marriages, generating life-threatening health problems. “The one thing I regret is what I did to my husband,” says Bev, a middle-aged woman from rural Quebec who was diagnosed with bipolar a few years ago. “He was a good man and we would have had a good retirement together.”
Bev was diagnosed with bipolar in 2006, following years of unrelenting depression and anxiety. She had a strong family history of mental illness: Her mother died by suicide; her daughter is clinically depressed. But it wasn’t until Bev reached her early 40s that her sexual impulses underwent a sudden change. She began “doing things I had never done before.”
It began with extramarital affairs, mostly with younger men: “It was as if my husband couldn’t see what was going on. He finally asked me and I said ‘no.’ The second time he asked me I couldn’t lie,” Bev recalls.
At least one study found that hypersexuality appears to play a larger role in women’s lives than in men’s. The 1980 study, led by Kay Redfield Jamison, PhD, a clinical psychologist generally regarded as one of the foremost experts on bipolar disorder—and one of its most well-known sufferers—reported that women with bipolar tend to be far more sexually provocative and seductive than their male counterparts. Further, Jamison found that twice as many women as men reported sexual intensity as “very much increased” during hypomania. The women in her study also rated sexual intensity as the most important and enjoyable part of mania.
Despite such findings, personal sexuality is a subject often avoided on the psychiatrist’s couch. Indeed, patients complain that their doctors rarely want to hear about it. Whatever insights they’ve arrived at have come by way of friends and fellow patients, they say.
Consider Jane (not her real name), a 20-something woman from the New York metropolitan area, who was diagnosed for several years with bipolar disorder before recognizing that her risky sexual behavior had a name and an explanation. The person who educated her on that score was neither her psychiatrist nor her therapist. Rather, it was one of her sexual partners, a man who himself happened to be diagnosed with bipolar.
“It’s your bipolar disorder that’s making you do it,” he told her. This insight left Jane with a huge feeling of relief. “You don’t want to be a slut,” she says. “I was stigmatizing myself with that ‘slut’ label for a long time. It was time to let it go.”
“Manic people are not embarrassed talking about sex,” says Barbara Geller, MD, professor of psychiatry at the Washington University in St. Louis. “It’s the doctors who are embarrassed—especially in child psychiatry: I’ve had colleagues who’ve said they don’t want to ask that question.”
Geller, on the other hand, has been asking it a lot. The author of a groundbreaking study about hypersexuality behavior in children with bipolar, she has helped overturn widespread assumptions through her research. Before her study was published in the December 2000 issue of the Journal of the American Academy of Child & Adolescent Psychiatry, experts widely assumed that overt sexuality in young children was almost always a sign of sexual abuse.
Geller’s research disproved that assumption; it found that flirtatious, sexual behavior was a common symptom in 30 percent of young, prepubescent children with mania and in 60 percent of the adolescents.
After ruling out the possibility of sexual abuse, Geller found that these behaviors weren’t confined to excessive masturbation and other forms of sexual self-stimulation. She described the case of an openly flirtatious 10-year-old boy who told a 50-year-old visiting nurse that he’d like to put on some dance music, because “I dig older women.” She told about parents of children with bipolar who reported that their little boys often tried to rub up against or touch the chests of older women, or reach up to pat a strange woman’s behind at the supermarket. Children can carry this behavior into school with them, making overt sexual comments to classmates or teachers, or touching themselves or others inappropriately.
For parents, this can be a double whammy. It is not uncommon for teachers and social workers to suspect parents of causing the inappropriate hypersexual behavior they see in schools, according to Susan Resko, executive director of Child & Adolescent Bipolar Foundation (bpkids.org), a childhood bipolar support organization.
“When parents come into school for a conference, they, or someone else in the household, are often suspected of sexual child abuse, responsible for the child’s hypersexual behavior,” says Resko, who feels that there is a very low general understanding of how bipolar disorder affects children.
Manic people are not embarrassed talking about sex. It’s the doctors who are…
“Families want all the help they can get,” says Geller. “They’re not embarrassed by discussing it. And patients aren’t embarrassed by it. It’s the psychiatrists who are embarrassed.
“Even highly respected colleagues who do research in the area have to be prompted to ask questions,” Geller continues. “I tell psychiatrists, ‘you must ask these questions because it’s terrifically important to find out. You want to know if a hypersexual child might be making up romantic fantasies about a teacher. You want to protect them until we can get them stabilized. You want to keep them safe from committing suicide, safe from getting AIDS.’”
Joseph R. Calabrese, MD, professor of psychiatry and director of the Mood Disorders Program at Case Western Reserve University, agrees with the importance of introducing the topic with patients. “All psychiatrists should first ask, ‘has your physical energy increased? Has your sexual energy increased?’ This should be followed by a question about impulsive new relationships and impulsive sex during the mood swings.”
Calabrese points out, however, that masturbation is less relevant when discussing hypersexuality with patients. “Impulsive new relationships and impulsive sex frequently involve risk-taking behavior to both the self and others,” he says, “but masturbation normally does not.”
Those conversations did not take place for Jane, the New York woman. When she finally told her therapist about her hypersexuality—including the details of her own personal wake-up call with a stranger who refused to wear a condom—the therapist appeared uncomfortable and merely urged her to “be careful.”
Being “careful,” of course, is precisely what some people with bipolar struggle to achieve. Just as someone coping with mania might not stop at $50 when his credit card allows him to spend $5,000, he may also devote hours each day staring at Internet porn or searching for partners. It’s the excess that gets him into trouble.
For Behrman, hypersexuality is not just the primary symptom of his illness; it is also the most challenging one. His book, Electroboy, is filled with raw depictions of sexual obsession, hustling, having sex in exchange for cocaine.
“When you’re hypersexual, you’ll be six hours late because you’re busy,” says Behrman, who’s currently working on another memoir, this one tentatively called Sex Junkie. “It becomes your secret little world. Your door’s closed, you escape to this world of sexual fantasy, your mind is racing, and this is the direction your mind is racing to.”
These days, as the father of two young children, Behrman recognizes the responsibilities parenthood has brought. “I’m extremely conscious about boundaries,” he says. “My private life is private. I have a 2-year-old and a 4-year-old and I spend most of my time being protective of them—which means protecting them from any symptoms of my illness. Now, I’m hyper-vigilant about my symptoms.”
He knows his old behaviors led to a lot of poor judgment calls in the past. “Bad things, scary things have happened to me,” he admits. “You put yourself in a lot of danger when you’re naked and stripping in a club.”
The club scene has been a regular, weekend haunt of Andrea, a well-spoken, 36-year-old Denver professional who was diagnosed with bipolar disorder in 2000. Like several other women interviewed for this article, she originally sought help after a friend expressed concern about her risky sexual behavior.
“I did a lot of bad things, made a lot of bad choices, and suffered a lot of bad consequences,” she says, sounding a lot like Behrman.
Andrea frankly identifies herself as a predator in the longstanding male tradition of the Don Juan. Proud of her looks, she offers up, unsolicited, a description of herself as a “very attractive woman, six feet tall with a lot of legs going on,” possessing an aura of sexual energy that draws men like bees to honey.
“I’m a woman who pursues men and once the pursuit is done, I’m done,” she says. “There’s a man in the club whom I didn’t particularly care about,” she goes on. “But once someone told me his girlfriend was there I pursued him; I went after him quite vigorously. Now I’m done with him—the chase was too easy. He’s gone and he doesn’t even know it.”
One minute Andrea is boasting about her sexual prowess, the next minute she rues the havoc it has wreaked on her marriage (“I was never faithful”), her self-esteem, and her physical health. The first therapist she saw was coldly judgmental (“You really shouldn’t be doing this,” she scolded). Andrea left her office flooded with feelings of shame and worthlessness. “I know it’s something I should control myself. But it almost physically hurts, because I want to engage in sexual activity so bad.”
Andrea has been treated for multiple sexually transmitted diseases. Yet one of the things that troubles her most, she says, is the thought that, deep down, she’s unable to love: “Because with me it’s always physical.”
Of course, not everyone who has extramarital affairs or indulges in pornography has bipolar disorder. But people with bipolar are at special risk of hypersexuality or—what’s more or less the same thing—sexual addiction, according to Louis J. Cozolino, PhD, a professor of psychology at Pepperdine University in southern California.
Cozolino attributes their vulnerability to a “disinhibition” of social restraints during manic periods. In other words, they are unable to act with an eye toward future consequences of their behavior.
“It’s like the CEO in their brain goes off to Bermuda,” says Cozolino, author of the 2006 book The Neuroscience of Human Relationships: Attachment and the Developing Social Brain.
Cozolino defines the brain’s attachment circuitry as the area that helps soothe emotions and tamp down fear. An important part of that is due to the amygdala, an almond-shaped structure deep inside the cerebral hemisphere that regulates fear and panic, and controls the endorphin receptors related to a feeling of well-being.
Numerous MRI studies have confirmed that bipolar patients have significantly greater cerebral blood flow to the left amygdala, suggesting that abnormalities in this brain structure may be implicated in the illness.
When I was younger, the sex was more about getting attention.
“We know that in bipolar the homeostatic regulation between the amygdala and other areas of the brain are out of balance,” Cozolino explains. He adds that during sexual arousal and orgasm, biochemicals are activated that generate a feeling of safety and calm.
“It doesn’t last long, it’s not the real thing, but it’s a really pleasant substitute,” says Cozolino. “So think of hypersexuality as an addiction. As an addict you never get enough of a drug….With bipolar disorder you have people who are more vulnerable to using sex as an addiction because they use it for soothing.”
Most bipolar patients with hypersexuality recognize the truth of this statement. “The very thing you think you want—intimacy—is the thing you’re afraid of,” says Karen of Long Island, New York. “You masturbate five or six times a day, you have phone sex, and at some point the sex feels really good and you get addicted to it. It’s a painkiller.”
Karen describes herself as a “Miss Goody Two Shoes” before mental illness kicked in when she was still in middle school. Raised in a middle-class family, she established a strong spiritual connection to God several years ago. Recently, Karen completed a 12-step treatment program for sex addiction that finally began to address deep healing issues.
“When I was younger, the sex was more about getting attention,” Karen says. “I had no boundaries. There was a lot of sexual abuse that happened to me. Although I was not molested, I always felt like a sexually abused person….I felt in some way that because I was compromised emotionally, I could not protect myself. Or else my impulse control was so off.”
In American and Canadian cultures, guilt is typically so attached to sexual activity that it’s sometimes hard to say what truly constitutes hypersexuality. A middle -aged woman with bipolar who lives in Texas is convinced that if it hadn’t been for the influence of her fundamentalist church 20 years ago, she would almost certainly have turned into “a whore.” This is despite the fact that, as she tells it, she’s had sex with only a handful of men. Still, she masturbated regularly, daydreamed about sex “all the time,” and was so wracked with guilt that “I ended up in my clergyman’s office many times, trying to deal with it.”
Now 50, this woman has three daughters, all of whom have been diagnosed with bipolar and who suffer from what she refers to as “serious libido issues.” The two older daughters are medicated; the youngest, who is 12, is being treated with diet (no dairy foods) and religious counseling.
While doctors sometimes prescribe medications developed for obsessive-compulsive disorder for people with hypersexuality, many patients are dismissive of their effectiveness. Behrman, for example, says he’s been on 37 different drugs and has never found the “hypersexuality medication.”
It is well established that the selective serotonin reuptake inhibitors (SSRIs) are associated with a lowered sex drive. Yet SSRIs are rarely if ever used for bipolar patients, since they could trigger manic episodes. Lithium, however, is well known for its dampening effect on sexuality, and has long been used for its stabilizing effect on the marriages of patients who have bipolar, according to Manic-Depressive Illness by Jamison and Goodwin.
“The issue with SRIs is that they can increase libido, and actually cause hypersexuality for people with mania,” explains S. Nassir Ghaemi, MD, director of the Mood Disorders Program at Tufts Medical Center. However, he says, those same SRIs can reduce libido for people who do not have bipolar, noting the subtle distinctions of the use of the same drugs for different patients.
“The mood stabilizers do not cause sexual dysfunction directly, or reduce libido directly,” Ghaemi adds. “By reducing the mania, the hypersexuality is also reduced.”
In any case, medication compliance is strongly recommended, along with regular sleep and meals—both are important first steps in getting a person with bipolar stabilized.
“No one can grow and become healthy while struggling with that kind of [biochemical] disregulation,” says Cozolino. “It takes all their energy just to survive the biological storms.”
It is only after a patient has been medically stabilized that therapy can be effectively introduced. “From a psychodynamic point of view, you’re trying to develop close and trusting relationships, to ‘re-parent’ the brain and build the circuitry that’s absent,” Cozolino explains. “And the fact that the brain remains plastic throughout life makes that possible.”
Therapy takes advantage of this plasticity and uses it to develop a new parental relationship between therapist and patient, in effect recreating the missing mother-child bond. That theory borrows from a growing body of research that places primary importance on the mother-child relationship. According to Geller, who has overseen much of that research, the most critical predictor of outcome in children with bipolar disorder is maternal warmth.
“[This is true] regardless whether the parents are themselves bipolar or not,” she adds. “In addition to pharmacology, it’s very important to look at mother-child relationships and do what you can to intervene there.”
Recreating this maternal warmth—if possible—may take years, but Cozolino, who is in private practice in Los Angeles, says he has had some success with borderline patients who share a similar psychological makeup with bipolar patients. (In fact, this is just one way of addressing the symptoms via therapy.)
The significance of maternal warmth is something that resonates for patients like Karen, who recalls the adolescent girl she once was—the one for whom boys lined up outside the bathroom door, waiting to have sex with her—and sees “an outcast, an untreated bipolar person who’d do anything to get attention.”
Thirty years later, Karen recognizes that her parents always tried to do the right thing, even if that included enrolling her as a 5-year-old child in a Weight Watchers class. “They couldn’t stand that I was overweight,” she says. “The message all my life was you’re not good the way you are.”
Even today, food is Karen’s drug of choice. But a careful regimen of medication has helped regulate her rapid-cycling and mood swings, while her religious community has given her a sense of belonging: Karen says she is in full recovery. This doesn’t mean she has become a “good girl,” however.
“You don’t forget what happened to you when you were in that manic phase,” she says, referring to the hypersexuality. “I can’t make it go away now that I’ve found God. I can say no to giving people money. I can say no to sex…I can say no sex until I’m married. But even if I get married to someone tomorrow, am I able to be a demure little housewife? No, I don’t think so.”
Printed as “Opening the Door on Hypersexuality”, Spring 2009
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