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(2011). Journal of American Academy of Psychoanalysis, 39:77-92
Driven Sexual Behavior in Bipolar Spectrum Patients:
Psychodynamic Issues
Jennifer I. Downey, M.D.
Recent psychiatric attention to the bipolar spectrum conditions
(Bipolar I, Bipolar II, and Bipolar NOS Disorders in the DSMIV-TR) has revealed that many more individuals are affected by
bipolar disorder (BD) than was earlier appreciated. Increased
sexual thoughts, impulses, and risk-taking sexual behavior are
recognized symptoms of the bipolar conditions when individuals
are manic or hypomanic. There is little scientific information on
the prevalence of symptoms of driven sexuality in individuals
with the less severe forms of BD as well as those individuals
with severer forms of the disorder who are recovering or have
recovered from an episode of mania or hypomania.
This article discusses the use of developmentally oriented
psychotherapy for an individual with a bipolar spectrum
condition whose symptoms were well controlled on medications
except for her driven sexuality. Current concepts in
psychodynamic psychotherapy offer a way to understand and treat
sexual symptoms in many individuals with less severe or partially
treated BD.
Since the observation that lithium carbonate given on a daily basis reduced
severity and frequency of episodes in individuals with manicdepressive
illness (Goodwin & Jamison, 2007), the attention of psychiatrists has been
drawn to biological interventions to stabilize mood in people with the
condition we now call Bipolar Disorder (BD). In addition to the mood
stabilizers, a number of other classes of drugs have been shown to be helpful
including anti-psychotics, anti-depressants, and in some cases,
benzodiazepines and stimulants.
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The author gratefully acknowledges the support of the Group for the
Advancement of Psychiatry's Human Sexuality Committee—Drs. Stuart
Adelson, Robinette Bell, David Goldenberg, Elizabeth Haase, Arthur
Schore, and Ralph Wharton, and Co-Chair, Dr. Richard C. Friedman.
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The dramatic response of bipolar individuals to psychotropic medications,
however, has not completely solved the clinical problems of patients with
these conditions. Only 25% of treated BD I patients have been reported to
recover fully (Keck, McElroy, Strakowski, West, Sax et al., 1998). In
bipolar patients receiving pharmacotherapy alone, rates of recurrence are 4060% over the next one to two years (Gitlin, Swendsen, Hendlin, &
Hammen, 1995). In a review of adjunctive psychotherapy for BD, Miklowitz
reported that psychotherapy was associated with 30-40% reductions in
relapse rates over 12- 30-month periods after an episode of affective illness
(2008).
Manualized psychotherapies such as interpersonal and cognitive
behavioral therapy, which can be performed in a standardized and
reproducible way, are the ones which have been most widely studied. These
therapies share certain similarities with psychodynamic psychotherapy but are
not identical. Effectiveness of psychodynamic psychotherapy has not been
studied in large groups of patients with BD up to now.
Bipolar disorder is a heterogeneous condition whose symptoms, severity,
and comorbidities (e.g., with substance abuse and/or obsessive-compulsive
disorder and/or personality disorders) vary. As Miklowitz notes, BD is a
highly chronic, disabling, and recurrent illness, and our existing treatment
options are inadequate for maintaining long-term stability. The reasons why
psychotherapy in tandem with psychotropic medication yields better outcome
than medication alone probably depend on the type of BD as well as the
comorbidities, resources, and deficits of the affected individual and his or her
family and are at this point poorly understood.
The unique contribution that psychodynamic psychotherapy has to offer the
bipolar individual derives from its focus on development. Understanding the
family history, circumstances of upbringing such as religion, education, and
degree of economic security of rearing, as well as the history of trauma, are
important in the evaluation and treatment of any psychiatric patient. Given that
bipolar individuals have a disorder which is largely genetically determined,
developmental factors are if anything, even more important. Because of the
presence in the home of caregivers and other family members with bipolar
and its associated conditions, many bipolar individuals have grown up in
homes suffused with affective instability, substance abuse, and chaos. The
developmental effects of this exposure during the vulnerable phases of
childhood and adolescence should not be underestimated (Adelson, 2010).
Verbal therapies are probably always less important than medications
when bipolar individuals are acutely psychotic, manic, or so profoundly
depressed that immediate intervention is needed to establish safety and
behavioral controls. The real value of individual psychotherapy
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becomes evident when the acute episode begins to come under control or after
that, when the overt symptoms of the disorder subside but residual symptoms
remain.
In the last decades, psychiatry has looked more carefully at the question of
what constitutes BD. In addition to Bipolar I Disorder, characterized by
episodes both of depression and frank mania, psychiatric attention has turned
increasingly to less severe forms such as Bipolar II Disorder, characterized
by depression and hypomanic episodes, and Bipolar Disorder NOS, a group
of disorders with bipolar features that do not meet criteria for BD I and II
(DSM-IV-TR; APA, 2000). Considered together, these disorders constitute a
group of conditions that have come to be known as the Bipolar Spectrum
Disorders (Merikangas, Akiskal, Angst, Greenberg, Hirschfeld et al.,
2007). BD I occurs in about 1% of the population; BD II has been estimated
to occur in another 1% of the population. But when individuals who have
subthreshold symptoms such as episodes of hypomania without major
depressive episodes or intermittent depressions and fewer hypomanic
symptoms than meet current criteria and also have bipolar family members,
the total life-time prevalence of these three kinds of BD is over 6% of the
population (Judd & Akiskal, 2003). The significance of this for clinicians is
that more patients will have symptoms of the bipolar spectrum disorders than
was previously appreciated.
Sexuality in Individuals with Bipolar Disorder
One of the symptoms that clinicians generally believe is characteristic of
BD is some type of disordered sexuality. In fact, in its definition of mania, the
DSM includes “hypersexuality” in two places. The first refers to increased
sexual activity as part of a general pattern of “increased goal-directed
activity” (Criterion B6). The second refers to “excessive involvement in
pleasurable activities that have a high potential for painful consequences”
(Criterion B7; p. 362). This suggests diminished impulse control and/or poor
judgment in the expression of sexual activity. The same criteria are noted in
the DSM for hypomania (p. 368).
Hypersexuality may also be evident in other disorders, and in fact, the
Gender and Sexual Identity Disorders Workgroup preparing DSM-V has
considered listing hypersexuality as a disorder in itself (Kafka, 2009; Kaplan
& Krueger, 2010). This diagnosis, if made, however, would not refer to
disordered sexuality that occurs in the context of manic or hypomanic
experience and activity.
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Although clinicians believe that heightened sexual drive, increased sexual
activity, and greater sexual risk taking are all more likely to be found in
bipolar individuals when in a manic or hypomanic phase, the literature
supporting this is actually quite sparse. For instance, in the comprehensive
textbook by Goodwin and Jamison, Manic Depressive Illness (2007), two
pages are devoted to sexuality in bipolar individuals out of a total of almost
1800 pages. Goodwin and Jamison note the paucity of studies, summarizing
that across the seven they review 57% of manic patients displayed
hypersexuality with 29% of patients demonstrating “actual nudity or sexual
exposure” (p. 348).
Some clinical investigators have reported that manic women are more
likely than manic men to experience some type of hypersexuality. Jamison and
colleagues observed that bipolar women rated increased sexual intensity as
the most important change they experienced during hypomania and that bipolar
patients were significantly more likely than unipolar patients to feel the
increased sexual intensity was a lasting characteristic (italics added)
attributable to their mood disorder (1980). If this were valid, it would mean
that in this population increased intensity of sexual desire and experience
could be a trait and not just a result of an altered affective state.
It is important to consider that not all individuals with BD have
hypersexuality as a symptom. Winokur, Clayton, and Reich reported that over
60% of patients with bipolar mixed states reported decreased sexual interest
(1969). About three-quarters of bipolar depressed patients report decreased
sexual interest (Goodwin & Jamison, 2007). Also, prophylactic lithium has
been noted to be associated with loss of sexual intensity and drive (Goodwin
& Jamison, 2007).
Even some frankly manic or hypomanic people do not display a change in
sexual behavior and possibly, may not even experience a change in sexual
feelings (to my knowledge, this has not been carefully studied). Reasons for
this variability have not been discussed. For instance, it is possible that it
might be attributable partly to biology of the particular variant of BD the
individual has and partly to his or her psychosexual developmental history.
The Psychodynamic Approach to Individuals with Bipolar Disorder
When individuals are in the middle of an acute mania—whether psychotic
or not—medication and behavioral controls are the treatment intervention of
choice. But when the patient's manic symptoms begin to
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come under control or when they were not so severe in the first place, the
psychodynamic developmental history of the patient becomes relevant. The
aim of this article is to discuss how a psychodynamically informed approach
to a core aspect of the patient's life—his or her sexual behavior and feelings
—may advance the clinician and patient's understanding and enable the
clinician to work with the patient to improve function.
The term, a “psychodynamic approach,” requires a word of explanation.
Originally, a psychodynamic approach was considered to be a perspective
determined by psychoanalytic principles, especially the idea that conflict was
the source of neurotic symptoms, and that conflicts arose from the relationship
between the three parts of the mind—the id, the ego, and the superego (Moore
& Fine, 1990).
More recently, the definition of what constitutes a psychodynamic
approach has been broadened to reflect newer ideas from psychoanalysis.
Gabbard's recent definition of psychodynamic psychiatry reflects this. In
2005, he wrote:
Psychodynamic psychiatry is an approach to diagnosis and
treatment characterized by a way of thinking about both patient and
clinician that includes unconscious conflict, deficits, and distortion
of intrapsychic structures, and internal object relations and that
integrates these elements with contemporary findings from the
neurosciences. (p. 4)
There has been virtually no recent attention paid to psychodynamic
influences on the psychopathology or treatment of individuals with BD. The
older psychoanalytically oriented literature has become outdated and is
largely invalid. This includes the work of authors who conceptualized mania
as a psychologically determined defense against depression such as Abraham,
Deutsch, Rado, and Lewin or as a “search for the good mother” (Cohen,
Baker, Cohen, Fromm-Reichman, & Weigert, 1954).
This lack of attention extends to psychodynamic influences on the sexuality
of patients with BD of all kinds, that is, individuals on the bipolar spectrum.
The importance of this is considerable. For example, reckless sexual
behavior with destructive components toward self and others is a major
health problem contributing to sexually transmitted diseases and unwanted
pregnancies throughout the world. Although data indicating the prevalence of
bipolar patients among those who have unsafe sex are not available to my
knowledge, common sense and clinical judgment suggest that they do
constitute a subgroup of such individuals. Data indicating the prevalence of
bipolar individuals among patients with diagnosed sexual disorders or among
patients with marital problems and associated sexual difficulties are also not
available.
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Probably, a meaningful subgroup of bipolar individuals exists among such
clinical populations. Families in whom intergenerational problems with
sexuality are prominent (for example, early age of onset of sexual activity
associated with childhood sexual abuse), are another clinical group in which
one might find many bipolar families although again data demonstrating this as
fact are not available.
Modern psychodynamic understanding of psychopathology is rooted in a
developmentally oriented history. The vignette below has been selected to
illustrate how the sexual experience and activity of a woman with bipolar
spectrum disorder could be understood using a developmental sexual history.
It demonstrates, as well, how psychodynamically salient motives—some
unconscious—appeared to influence her sexuality. This psychodynamic
understanding made possible effective treatment of her residual symptoms in
the area of sexuality.
Case Vignette
H was a 33-year-old single professional woman* with BD NOS
when she consulted me for the complaint, “I want to get married but
I keep seducing men.”
Psychiatric History: H had been diagnosed for the first time when
she saw a psychiatrist at the age of 21 for her second hypomanic
episode. At the time, she had been in college, working very hard on
her studies and in a part-time job, when she developed increased
energy, an inability to sleep more than 3 hours a night, the belief
that her senior thesis could be a work of genius, and generalized
euphoria. A previous hypomanic episode had occurred during her
first year away from home at college. This episode had not been
identified at the time as it resolved without treatment when the
patient went home for the summer and resumed a more structured
schedule. H denied every having had an actual major depressive
episode but she had suffered from day-long episodes of
premenstrual irritability and tearfulness and had also had some
other periods of feeling “down” for several days which had
resolved spontaneously.
At the time when the 21-year-old H was seen at the student health
service, she had been thought to be in the early stages of developing
BD and the treating psychiatrist had considered she might be
developing BD I, BD II, or BD NOS. She was given a leave of
absence from college for a semester, was put on mood stabilizers,
and had done well since then. Her symptoms had resolved over the
course of 4-5 months after being put on medication. Neither the
patient nor her family had thought her sexuality at the time was
different than usual.
—————————————
* The personal clinical material in this article has been disguised.
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She had not had any subsequent episodes of illness, and was
followed by a psychiatrist several times yearly for renewal of her
medications. By the time she consulted me, it had become clear that
H was on the bipolar spectrum, but because she had never had a
frank manic attack nor an episode of major depression, the
diagnosis of BD NOS could be now be made definite.
History of the Presenting Complaint
H sought consultation because she hoped to get married but found herself
in a pattern of seducing men, having passionate relationships with them, and
then moving on. She reported that “my sexual motor is always running.” She
could go to a bar or cocktail party, lock eyes with a man, go home with him,
and spend anywhere from a night to a three-day weekend having sex with him
many times. She was multiply orgasmic and greatly enjoyed a variety of
sexual activities with men, but she told the therapist that the real excitement
was in making that “initial connection” and “seeing him falling for me right in
front of myeyes.” Recently, a number of girlfriends had married, and H had
started to wonder if she was really “on track” to do so as well. With
considerable self-awareness, she thought she was not.
H invariably used condoms when sexually active and had never had the
experience of having a liaison with a man who was dangerous. However, she
“lost whole weekends of her life” and sometimes failed to complete
professional tasks she took home because of it. H also noted that she
preferred married men since they were less likely to pursue her on a longterm basis. When no men were available, H masturbated daily for a half hour
to an hour, using her vibrator. Her sexual interest and behavior seemed like a
trait to her. It did not vary with her mood, the amount of sleep she got, or other
life events.
Past Personal, Family, and Sexual History
H had grown up in comfortable circumstances in a medium-sized city in
New England. Her father ran a successful retail business, and her mother was
a housewife. One of two children and the only daughter, H had a brother three
years younger, who had a difficult temperament, interpersonal problems at
school, and had never been close to the patient. She reported that the most
memorable thing about her childhood was her parents' relationship. They had
always had an intense connection with bickering and joking, interspersed with
much display of physical affection and interest—kissing, hugging, and
grabbing at sexual body
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parts—all in front of H and her brother. H's father had hypomanic traits and
was flirtatious with women, who greeted him with delight at his country club.
H said, “My father never met a stranger.” So far as H knew, her parents were
monogamous, but always made it clear to their children that they maintained
an active sex life. For instance, they would retire to their bedroom on Sunday
afternoons and lock the door. No amount of pounding and wheedling would
get them to come out. H recalled listening to the sounds emanating from the
bedroom and realizing her parents were having sex. At age 10, H was
delighted to notice the first signs of her approaching puberty—the beginning
of breast and hip development and adult body hair. At age 11, H had begun to
masturbate, and did so to the fantasy of having sex with a desirable older boy
and having him choose her over his girl friend. At age 15, H was delighted to
discover that boys and men “connected with me, wanted me.”
H had affective disorder on both sides of her family Her paternal
grandmother had been psychiatrically hospitalized several times and spent the
last decade of her life taking lithium. Her mother's father and his brother had
both suffered from depressions.
At the time of the consultation, H was a college graduate with a business
administration degree, who worked in a corporate environment as a middle
manager. Her job was demanding, and she functioned well at it most of the
time with the exception of the occasional “lost weekends.” Careful
interviewing, however, revealed that she sometimes had liaisons with
colleagues or clients of her firm. This was strictly against company policy
and she ran the risk of termination if she was caught. This would have caused
her a severe loss of face in her work community.
She reported no other hypomanic symptoms other than her elevated sexual
drive and sensation-seeking sexual behavior. For instance, she slept well and
was sleeping for as many hours as was her habit. Her performance at work
was respected, and she had recently been promoted. She did not appear to
abuse substances. Her only medications were divalproex sodium 750 mg/day,
clonazepam .5 mg occasionally for anxiety (2-3 times per month), and oral
contraceptives.
The Psychodynamic Psychiatrist's Assessment
H appeared to have BD NOS. Depressive symptoms when they occurred
were mild and lasted no more than two days at a time. She was a friendly,
energetic, witty woman with a mood that appeared to be sunny, not elevated.
Because H was reporting unusually high sexual interest and activity for a
woman of her age, I considered the possibility
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that she might be slightly hypomanic on her current regimen of medications,
but I could elicit no other symptoms of hypomania. There was no evidence of
any other Axis I or II disorder.
Then I considered H's sexual history and personal narrative. Both parents
seemed to have loved H and provided a secure environment in which to grow
up. She could report no instances when the family seemed to be out of control
or when she was without adequate protection. She remembered being her
father's favorite child, but felt that her mother always took precedence over
her. In particular, H recalled being bored and lonely on Sunday afternoons
and other times when the parents had sequestered themselves in their
bedroom. She knew her parents were having sex and eventually became
sexually excited by that thought and masturbated to it. The family had been
somewhat relaxed about nudity. H had been allowed to enter the bathroom
when either of her parents was bathing but did not recall finding this
consciously arousing. She had had exciting experiences with kissing games as
a preteen, had masturbated to orgasm beginning at age 11, had had her first
boyfriend at age 15 and had her first experience with intercourse with him.
She had never had any sexual attractions or experiences with same-sex
partners; and she had no history of significant trauma or boundary violations
as a child other than the experiences with parental nudity mentioned above.
She and her brother had always had a distant relationship and had never
explored each other sexually. H recalled playing with baby dolls as a young
child, but from middle childhood on, she could recall no conscious memories
of wanting to be a mother or have children and this had continued into
adulthood.
I then considered the part of H's narrative that was beyond her awareness.
Now that H was sexually mature herself, she got great pleasure from seducing
men, especially men who were already attached, symbolically triumphing
over the women they were married to. H enacted her childhood experience of
trying to get her father's attention but with a different, more powerful ending:
She got the man. She had sex with the man. Then she abandoned the man.
This fantasy was unconscious. She did not realize it drove her behavior. On
the contrary, H enjoyed a close relationship with both her parents, and liked
the men she seduced and abandoned. She had never understood why she
ended sexual relationships when she did. She had no conscious fantasies of
abandoning sexual partners. On the contrary, she fantasized—albeit vaguely
and infrequently—that someday she would meet someone and live happily
with him for a long time. Mysteriously, her behavior always made this
impossible. Her desire for competitive triumph over women and dominance
over men appeared to be completely unconscious.
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I speculated that this repetitive narrative could be understood in traditional
oedipal terms. She felt the need to enact a triumphant defeat of her mother and
obtain the forbidden male sexual object. The abandonment of the lover,
however, was presumably motivated by unconscious guilt and anxiety. In her
unconscious fantasy there would be no retaliation against her because she had
already been “punished” by giving up the man. This aspect of the unconscious
fantasy was a compromise formation. The sexual activity motivated by the
fantasy was reckless and potentially self-destructive. The fact that no
vocational catastrophe had yet occurred was at least partially accidental.
Of course, any piece of psychopathology serves multiple psychological
functions. Another function of the patient's unconscious fantasy and enacted
activity was to express her mistrust of men, more particularly, her fear that if
a relationship were to continue, a man would “dominate” and control her. If
that happened, she would lose much valued autonomy. The patient had never
imagined or fantasized about a partnership with a lover in which trust and
cooperation were truly possible. This could be understood by considering her
parents' behavior in her childhood home. H's parents had maintained a family
life that was highly sexually stimulating, but also one where when they
weren't making a playful or sexual connection, the parents were bickering and
struggling for dominance. H was unable to recall ever seeing either parent
appear vulnerable and thus truly trusting and loving in the theatre of the home.
The Psychodynamic Psychiatrist Makes a Treatment Plan with the
Patient
At the end of the assessment, I decided to discuss certain aspects of my
impressions with H. But first, I tried to establish how distressing this problem
was for her and how it was affecting her function. I asked, How badly did she
want to get married and have a conventional life style? How seriously was
her behavior affecting her work?
H told me she came from quite a conventional family. Her extended family
was close and big. Nobody in her family understood why she was still
engaging with men like this and never had anyone to bring home to family
functions. She felt there was “getting to be something wrong with it.” By her
cultural standards, she should be beyond it by now. H wanted a husband, a
man to do things with, make a life with. On the other hand, she had no
particular desire to have children. Having
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children was not a motivation to give up her life of serial seduction.
The answer to how her behavior was affecting her work was similarly
nuanced. H was proud that she had done well so far in the large corporation
where she worked. She acknowledged, however, that her liaisons with clients
and colleagues amounted to “playing with fire.” She noted that “I could be
bounced out on my ear” and that because her industry was close-knit, that
experience could affect her ability to get another job.
I then considered H's response to my remarks. The history suggested
physiologically determined self-stimulation. That is, the patient's elevated
sex-drive and sexual activity were likely to be biologically related to her
bipolar diathesis. However, H's stimulus-seeking behavior was stopping her
from achieving emotional intimacy with a man. Her life was beginning to lack
an age-appropriate stability. Girlfriends complained that she would leave
them at events to go with a new man she had just met. They considered this to
be irresponsible behavior and had told her so. It was also affecting her work
performance. Her sexual searching behavior was causing her to cross
boundaries at work that had been made explicit by management, and her
performance reviews had not suffered only because her behavior had not yet
been noticed. In other words, she had been lucky so far and stayed “under the
radar.”
Together, H and I considered the data. We concluded that her compulsive
seduction behavior was a significant problem. She wanted to make the effort
to change it. We considered several treatment options. One would be a
medication adjustment. For instance, it could be that she was slightly
undermedicated for her hypomanic predisposition and that an increase in dose
of her drug or change to another mood stabilizer might help her bring her
sexual behavior under better control. The answer to this was not immediately
obvious. Several medication modifications might need to be tried.
Another treatment approach was to engage in psychotherapy aimed to
understand and bring under better control two aspects of her behavior. The
first aspect was her repetitive, obligatory seduction, and consummatory
sexual behavior. The second was her need to end any sexual relationship, no
matter how socially appropriate it was and no matter how much emotional
sustenance it provided her.
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Course of Treatment
In H's case, we decided to use a combination of modalities. With a modest
dose adjustment of her mood stabilizer, her sexual preoccupations lessened to
the point where she became able to attend social functions without
interrupting them to initiate a new sexual liaison. Psychodynamic
psychotherapy was conducted with the patient sitting up in sessions of 45
minutes. Therapy continued for three years and addressed certain behaviors
that were complicating H's ability to control her impulses. H's social
behavior with men became less driven when we focused on regularizing her
life: making sure that her sleep schedule was stable, pursuing regular exercise
rather than bursts of intense work-outs interspersed with weeks of “couch
potato” behavior. Other than the medication adjustment, the most important
behavioral change made was to focus on H's consumption of alcohol at the
social events where so many of her “hook-ups” began. We realized that H
was extremely prone to disinhibition if she consumed more than a single
alcoholic beverage. This behavior had escaped notice because it occurred
with such a modest dose of alcohol that no one had recognized it as a variant
of a substance abuse disorder. Once she realized this, she became motivated
to reduce her alcohol consumption in social settings so that she retained better
social judgment. Her capacity, if she wanted to retain rational behavior, was
actually half a drink. H accepted this good naturedly, announcing that she was
now a “cheap date.”
The psychodynamic psychotherapy H received focused on several tasks.
We looked at her conscious and unconscious motivations and conflicts in the
different areas of her life—with her family, her friends, her lovers, and her
colleagues. We talked about how the events of her past had been made into a
narrative story (that it was socially constructed was obvious but not
something that we specifically went into). We talked about how the narrative
she was living demonstrated certain maladaptive patterns which were
repeated over and over. She came to understand how her developmental
sexual history had contributed to her story and, in particular, her compulsive
need to seduce and abandon men.
Attention to the transference was vital to the treatment. Because the
therapist was a woman, H began treatment with a maternal transference. She
expected the therapist to be competitive with her and to disapprove of all
attention H received from men. Initially, she manifested this by keeping
secrets in the treatment, trying to keep her relationships with men outside the
area of discussion. Analysis of this transference paradigm made it possible
for H to feel more secure in the relationship
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with the therapist and also in the relationships with her girlfriends and other
women. With slightly moderated sexual drive but mainly less anxiety (a
symptom that lessened without direct work on it), H became able to tolerate
relationships with men that were longer and afforded her the opportunity to
get feed-back about her sensation-driven, self-centered approach to them. An
intelligent woman, H was intrigued by her own behavior, worked hard in the
therapy, and eventually was able to develop relationships with one man and
then another that were friendships as well as sexual liaisons.
Discussion
The enormous advances in pharmacotherapy of individuals with BD over
the last decades have absorbed most of the psychiatric profession's attention
and interest. Modern psychodynamic psychotherapy approaches to individuals
with BD have received very little scholarly attention during this time. Yet
many of the therapists who do psychotherapy with bipolar patients could use a
psychodynamic or developmental approach. The developmental approach has
particular value in helping the high proportion of individuals on the bipolar
spectrum who have sexual symptoms while recovering from an episode or
even between episodes of illness. Sexual symptomatology in bipolar
individuals is a phenomenon that has been surprisingly little studied. For
instance, I am not aware of a single study addressing sexual symptoms in
individuals with BD when they are between episodes.
Psychodynamic psychotherapy can be vitally beneficial to bipolar
individuals with sexual symptoms. A major reason for this is that the sexuality
of an individual is determined not only by constitutional factors but by
developmental ones—especially experiences of affection, sexual stimulation,
trauma, and boundary violations or boundary security—occurring during
childhood. Elsewhere Richard Friedman and I have written about the
importance of the developmental sexual history for the understanding of the
mental life of psychiatric patients generally (Downey & Friedman, 2009).
Events in an individual's childhood, adolescence, and adulthood have a
lifetime formative effect on each of us. They form what different authors have
called the “sex print” or “sex script,” that is, the particular set of
circumstances and qualities of the object that each one of us finds arousing.
They affect not just sexual orientation and whether one has a sexual
dysfunction or not, but one's choice of partners; one's experience of sexual
pleasure and pain; one's ability to experience sexual passion, intimacy, and
love; and one's ability to make a close and lasting relationship with a sexual
partner.
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Psychodynamic psychotherapy for individuals with severe, chronic Axis I
disorders such as bipolar spectrum conditions serves manyfunctions. For
instance, psychotherapy with a caring and skilled therapist can instill hope,
remove stigma, and provide soothing. Similarly, psychodynamic
psychotherapy with bipolar individuals offers the chance to assist the patient
with achieving mastery—over his or her impulses and fears as well as the
chronic uncertainty about mood stability that every individual on the bipolar
spectrum experiences. Here we are focusing on a third function
psychodynamic psychotherapy can perform for individuals with bipolar
spectrum disorders and sexual symptoms—providing understanding and
ability to change one's life. By careful attention to the personal narrative of
the individual (which will always include—in the case of patients with BD—
the experience of the illness itself), the therapist is enabled to understand with
the patient the enactments he or she is living out.
I have used the example of H, the woman presented in the vignette earlier
in this article, to illustrate how psychodynamic psychotherapy can help an
individual understand and change herself or himself. By most clinicians'
standards, H's bipolar condition was not symptomatic, but H's heightened
sexual drive and activity seriously jeopardized her career and personal future.
On careful examination, this heightened sexuality appeared to be
multifactorial. It seemed that both her bipolar diathesis and the quantity of
sexual stimulation experienced in her childhood were likely contributors.
From a psychodynamic perspective, the patient was living out an oedipal
drama of sexual competition with her mother for the attention of her adored
father, a scenario that played out over and over again with her seduction and
abandonment of the men she met. Detailed attention not only to the patient's
psychotropic medications but to the meaning of this drama in the patient's life
made it possible for her to mature psychologically and achieve a more ageappropriate and flexible sexual adaptation.
In recent years psychiatry has been increasingly polarized between
biological determinists or “essentialists,” and social “constructivists.” This
reductionistic debate over whether behavior is determined by nature or
nurture is not useful for understanding most psychopathology and its treatment.
Its limitations are well illustrated when we consider the treatment of bipolar
spectrum patients generally and when we consider specifically, the challenge
of finding a clinically effective approach to the sexual difficulties such
individuals face.
Sexuality in individuals with bipolar spectrum conditions must be
understood as being the product of an interaction between nature and nurture.
This interaction has different meanings and consequences at different phases
of life. Since unconscious processes must be understood
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in order to shed light on the relevant interactions in any given patient, in
addition to those that are conscious, a developmental psychodynamic
perspective on behavior is useful. With respect to conceptualizing
psychopathology and treatment, this approach supplements that used in the
DSM.
The case vignette discussed in this article not only illustrates this, but also
another point as well. Patients tend to organize their fantasies conscious and
unconscious by constructing private story lines, or narratives. These are
influenced by the patient's life experiences. With respect to sexual experience
and activity, a sexual history taken by the clinician is useful for understanding
the internally experienced narrative, parts of which may be conscious and
parts unconscious. Psychotherapeutic work is informed and enhanced by the
therapist's understanding of the sexual history and personal narrative which
becomes linked to the patient's progressive understanding of it as treatment
progresses.
Individuals with the bipolar conditions often suffer—while recovering
from manic or hypomanic states and even between episodes—from
difficulties engendered by intense sexual urges and risk-taking sexual
behavior. This article makes the argument that the most effective treatment in
these instances is often a combined approach—making full use of the
psychotropic advances psychiatry now has in its arsenal, but using, as well,
the powerful therapeutic leverage gained from understanding the patient's
sexual history and personal narrative.
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Article Citation [Who Cited This?]
Downey, J.I. (2011). Driven Sexual Behavior in Bipolar Spectrum Patients:
Psychodynamic Issues. J. Am. Acad. Psychoanal. Dyn. Psychiatr., 39:7792