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Ask the Mental Health Expert Archives 2001-2004

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Bipolar's Perception

Q. Does someone who is bipolar understand the difference between right and wrong while in a manic or depressive state? I know that it certainly influences their behavior during those times but I have not found any evidence that it affects their value system as to what they believe is right or wrong.

A. My personal view is that severely manic or severely depressed bipolar individuals may show periods of very atypical behavior and thinking, during which their judgment in a variety of areas is extremely impaired. I know of one patient, for example, who carried out a robbery during what was probably a manic episode with psychotic features. This behavior was radically at odds with his usual behavior, as well as with his value system. Once he was appropriately treated, he certainly realized the immorality of his actions and felt very bad about it. Of course, it's very hard to get reliable data on an individual's value system while he or she is in the midst of a severe manic or depressive bout. And once they are in remission, their recollection is often fuzzy or subject to retrospective bias. For example, a patient may say, "I can't believe I did such terrible things, doctor. You must be mistaken."

My experience is not that people in the midst of a bipolar mood episode lose their sense of right and wrong; rather, they reach bizarre conclusions about what is right or wrong, based on distorted or erroneous interpretation of data. For example, the person with psychotic mania may be fiercely (and grandiosely) attached to a moral world-view, such as ridding the world of evil. But he may conclude that someone who is standing behind him with a letter opener is an evil-doer, out to stab him. This may prompt some defensive, but grossly psychotic, response, such as attacking the person preemptively.

This may be particularly true of manic individuals who are also abusing alcohol or other drugs of abuse--which is not uncommon. [By the way, let's not lose sight of the fact that most individuals with bipolar disorder and other mental illnesses are not violent or aggressive!]. I, too, was unable to find much empirical research on the question you raise. However, you may be interested in the article by Ratner in the Bulletin of the American Academy of Psychiatry & Law 1981;9(1):23-32. This described a young manic depressive man whose first contact with a mental health professional was in connection with a criminal act performed during a manic episode. The author reached the conclusion that "...the crimes occurred only as a manifestation of or in conjunction with the active phase of the illness..." which might imply that the person's sense of right and wrong was radically altered during the period of illness. But again--all we can usually do is re-construct the individual's mental state during the period of active illness.

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December 2001

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