It is time to think unthinkable.

Because it is time to bring out of closet the untalkable.

What it is? And why it is important.

Let there be a suspense for a bit and before coming straight to the point, let us look at diagnostic criteria of Bipolar Mania in  American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (DSM-5)

As per the Diagnostic Criteria for diagnosis of Bipolar Disorder I  at least one lifetime manic episode is required. But what how do we diagnose the episode of a Mania. DSM-5 has following to say for that.

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). 

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (eg, feels rested after only 3 hours of sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (eg, medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis.

(SOURCE DSM 5)

So why do we need to look at these criteria in the context of this blog. The reason is the blog has decided to remove the clock of secrecy from that one specific aspect of bipolar mania talking about which is banned at home, about which patients are seldom warned by practising psychiatrists and the sufferers them selves dare not talk about it either privately or publicly due to extremely high level of stigma surrounding it.

Yes the subject matter of discussion, here is Sexual Indiscretion in Bipolar Mania.

Is it not discussed privately or publicly because it is an extremely rare thing or because we as a society fear knowing the truth.

Instead of passing on a value judgement at this stage, let me delve deep under the carpet but let me also start with a shocking hypothesis-

“There  is causal connection between mania and heightened hyper-sexuality, promiscuity and sexual indiscretion even though Indian societal construct sexual-exhibitionism, promiscuity and lewdness represent immoral, unacceptable maladaptive behavior. A normative conservative Indian mind will be shocked to know, sexual derangement are precise norms in bipolar manic attack. DSM versions III to latest V all acknowledge goal directed increased sexual appetite and sexual indiscretion as key determinant of mania. With mania comes bundled plentiful of “sexual preoccupation, high hyper-sexuality, uninhibited sexual provocation, lewdness, shamelessness, nudity, exhibitionism, unpredictable promiscuity, multiple extramarital affairs.”

I know my above dare devil hypothesis will be questioned by both psychiatric community and bipolar patients, as well as lay man. But not telling the truth the way I understand today after decade and half research on the subject, shall be like keeping an unholy mum.

In search of truth I reached “Wisdom, Madness and Folly (1952)”, by John Custance, first authentic memoir of a manic depressive that I could lay my hands on. The book gives out of ordinary, insight into a bipolar mind. And what I have found in the writings of the Custance will be shocking to conservative Indian mind-

Custance wrote about his sexual dalliance during manic high- “Religious feelings and emotions combined with sexual impulses caused me to give away 300 pounds, (which I could ill afford) to ladies of easy virtues… First time I was accosted somewhere in Bond Street…it was a call. Someone wanted me and I could not refuse… I had found a mission. I could and must serve these women… I gave money away till my bank warned me about overdraft, but I was convinced God would give me money to carry on”.  (Wisdom, Madness and Folly Page 48)

He wrote further-

“Judging from my own experience, sexual symptoms of manic state seem to be most powerful and important… normal inhibitions disappear. Release of the sexual tension seems to me to be the primary and governing factor of all the ecstasies and many other experiences of manic state” (Wisdom Madness and Folly Page 44)

But this is the experience of one individual. That too immoral westerner .Why should we virtuous Indians care. Also one single case of such example in manic episode has to the .rather exception. It just can not be the norm . And definitely Indian Bipolar rooted in the Indian culture. We have strong value systems. This just is an odd exception.

Or is it really so? What is the real truth of Bipolar Mania?

Is hyper-sexuality and sexual indiscretion integral to it or just an incidental exception.

With these questions in mind I have dared to look at what is the scientific literature on the matter. And what I learn has both humbled and shocked me-

“What I have found is that there is abundance of plentiful scientific literature linking mania with inappropriate sexual behavior. Let us just look at the few-

 (a) Arteaeus of Capadocia, as early as  150 AD talked of definitive lewdness and shamelessness as predictors of mania.

(b) But Arteaeous was man of another era, science has got much more advanced today. What is the recent literature. I found it sobering to find that his findings about clear linkages between mania and sexual indiscretion is corroborated by Tuke in 19th century and  areHis findings are corroborated by others-Tuke in 19th century,  and by father of modern psychiatry Kraeplin in early 20th Century.

(c) Bluer the contemporary of Kraeplin the one who segregated the two stands of madness,  and separated Dementia Paracox (now known as Schizophrenia) also found the same inter linkages between mania and hypersexuality.

(d) The list goes on with validation of the intersection of mania and sexual indiscretion by  Campell and Mayer Gross towards middle middle of 20th century and by Spalt and Jamison towards end of 20th century.

The list keeps growing.

Goodwin and  Kay Redfield Jamison, based on meta-study of seven studies reported in 2007 that 57% of bipolar patients experienced heightened sexual energy, lack of inhibition and indiscretion during mania. This is hell of a number to be ignored

All researchers concur- “Sexual indiscretion is a key predictor of mania”.

Consequences of Sexual Indiscretion in Mania are many, they ruin relationships, destroy familial fabric, bring unwanted diseases and leave behind a truck load of destructive debris. Most often because it is pleasurable in nature, the impulsive, reckless sexual behaviors and significantly increased sex drive are not even considered as a problem.

Admitted an increased interest in sexuality on its own during a manic phase  should not be a big problem so long as it finds safe outlet but that is hardly the case. because the real problem is that Bipolar Mania does not have just one or two symptoms like fever and body pain,

The real problem in bipolar mania arises when hyper-sexuality and sexual indiscretion gets turbocharged with  other dangerous symptoms of bipolar mania —  impulsivity, risk-taking, beaviour and poor judgment, all these combined have lethal impact, and destroy the sanity of the person and send them reeling under irresponsible behavior which has huge collateral damage.

In last two decades I have come across a sample of four dozen such cases- men and women, boys and girls, inexperienced and mature, who have landed in trouble because this taboo untalked symptom of Mania. Few lost their relationship, yet in few other cases there was painful collapse of marriage. In couple of cases I also know of suicide attempts on this count. In a country this big, anecdotal sample of 50 is miniscule and unreliable.

But make no mistake. When the manic fever comes down and the sufferers reels in depression this sexual indiscretion in Manic face comes to haunt him and often in life. He or she dies every day but biggest sufferers are the family members.

Should we continue with the unholy silence? Should we merely dub it a western phenomenon?

Or should we do a sincere soul searching. Is it not time for at least psychiatric community to guide the sufferers of Bipolar Disorder that there can be such a situation and if such situation presents itself the person must ask for help.

In past two decades I have been treated by six psychiatrists and one therapist- only one of them had the courage to tell me this too is a problem.

SO is it not time to talk. or we will continue with our deadening silence with huge down size to sufferers and their families