Q:  Hypersexuality & Manic Episodes

Dear Dr. Phelps,
This is so embarrassing but what causes hypersexuality when your having a manic episode? I get horribly hypersexual and honestly it gets so bad my husband cannot take it because I want sex ALL the time. Then if he refuses me I throw a fit and feel horrible and jump to conclusions. I have even had affairs in a previuos marriage. How do I control this? Even being on meds (lamictal and abilify) i still get this way.

thanks,
Jessica  


Dear Jessica --

That is courageous of you to ask. There must be thousands of people who have wondered the same thing, and struggled with this symptom in a similar way. Indeed, this symptom must have had disastrous effects on relationships for centuries. Therefore it is fortunate, for others, that you have asked.

Most importantly, just as you have described it here, both those with bipolar disorder and those who love them need to recognize that this is a symptom of the illness. It would be so easy to form moral judgments about this behavior, and yet it is not really any different than "pressured speech" (having a lot to say, being difficult to interrupt); or "flight of ideas" (a wild imagination, or when things are more severe, disconnected thoughts that are not truly related to one another yet seem so); or any of the rest of the manic-side symptoms of bipolar disorder. Rather, our society and its moral judgments about sex make this symptom different from the rest of the manifestations of mania/hypomania (indeed, this may be more of an issue in Bipolar II, where there are fewer other symptoms of obvious "mania" to make it clear why hypersexuality is happening; i.e. there may be fewer other signs that a person is actually experiencing a bipolar mood/energy shift, and that's where the sexual energy is coming from, leaving open the interpretation, instead, that this person is just sexually hungry to an inappropriate degree).

What exactly causes this? Unfortunately, that is almost the same as asking what causes mania itself, which remains largely a mystery still. There are some fascinating new data on the molecular and genetic bases of mania (to accompany the fairly elaborate understanding of depression, which has shot forward in the last decade; for details there, see my webpage about "Depression is not a moral weakness"). These include one of my favorite recent headlines: "Gene Knockout Unleashes Manic Mouse", describing a recent series of experiments which showed the importance of a gene involved in the biological clock, highlighting further the importance of circadian rhythms in bipolar disorder understanding. 

Another relevant recent advance has been the increased understanding of the neuroanatomical basis of cocaine addiction, in which it is now clear that evolutionarily quite old brain structures involved in "reward systems" underlie the powerful effects of this stimulant. The neurotransmitter dopamine is very directly involved, leading to the production of our brains own heroine equivalents (endogenous opiates). An article I read recently emphasized the way in which cocaine seems to take over this pathway, which is directly involved in sexual pleasure. Likewise, people with bipolar mania seem to have a lower threshold for stimulation of this old pleasure center. When you put all those threads together, perhaps this says that part of mania is an increased desire to pursue (and experience) those states of high reward, sex being one of them.

Again, however, the most important thing is to recognize this as a symptom, just like decreased sleep. It could serve as a marker that mood/energy cycling has not been completely controlled. In that respect, you might want to talk with your psychiatrist about both non-medication and medication approaches you could consider to get more complete control of cycling (if this line of thought is correct, for example, it would predict that you're also having episodes of depression still, perhaps mild, but not zero; so that there would be additional reason to pursue more of a "mood stabilizer" effect then you are getting from your current treatment).Good luck with that.  Thank you for asking this question.

Dr. Phelps
 

Published September, 2007