In High Spirits: Some Links Between Alcohol Use and Bipolar Disorder

Her bipolar disorder stabilized, Janet reminisced about her 21st birthday. As high as a kite, she had downed three bottles of wine and numerous vodkas, while her amazed father had commented on how remarkably coherent she appeared to the guests. ‘Normally, half a bottle of wine makes me slurred and wobbly’, she told me. ‘What is it with mania?’

Her story is not unique and I have had bipolar patients describe drinking up to several hundred standard drinks over 3–5 day sleepless sprees. Increased risk of alcohol (mis)use in those with bipolar disorder is widely recognized as common at both poles. In a depressed phase it frequently reflects self-medication or pain relief strategies, but the interdependencies with bipolar highs have generated little sober consideration.

How is it that some manic individuals can seemingly turn wine into water? Many observe a higher threshold to alcohol intoxication at such times, just as many hospitalized manic patients tolerate high doses of benzodiazepines and antipsychotic drugs. But what is the nature of the suggested increased resistance, and which allows the disinhibiting effects of alcohol to predominate?

It may be that the sheer velocity of a mood elevation needs the disinhibiting fuel of alcohol. During a high, alcohol is craved by many, seemingly to stoke the fires, iteratively disinhibiting the individual, with heightened senses (e.g. ‘breathing in’ music rather than merely hearing it), the feeling of being interconnected to the world via a ‘semi-permeable membrane’; the one-ness with experiences. Such sensory overload is commonly reported during the gathering high. Some with bipolar disorder will describe a craving for alcohol even before any high is evident – seemingly to induce and accelerate that mood state. So, is there some pre-high tingling diathesis state awaiting a releaser such as alcohol? As the comedian Stephen Fry observed in his BBC documentary on bipolar disorder, alcohol use is even increased at times when the individual is “not depressed, not manic, just ‘on’”. Not a mixed state, not shaken, just stirred.

Is this not a variant of the switch phenomenon and, if not, why call a drink a ‘highball’? Such phenomena have classificatory potential. We know that any antidepressant drug can facilitate a high or a mood switch (sometimes called bipolar III). When asked, many bipolar patients describe alcohol-induced switching from depression to hypomania. Should alcohol then be included as a precipitant in the bipolar III category? (Or, consistent with the increasing subdivisions of bipolar disorder – currently up to bipolar VI – perhaps bipolar ‘7 Up’… might have patenting limitations.) Alternatively, an historical descriptor might be refashioned. Mania a potu is variably defined – and variably spelled, including mania a poti – but has been used to describe an extremely disinhibited state associated with alcohol excess. Perhaps it should be reserved for bipolar individuals who report alcohol-induced manic states.

And, as for other expressions of mood disorders, is there some value in delineating a subclinical or subsyndromal state? Not for those who are already in a mild high and then craving alcohol, but for those seemingly euthymic bipolar individuals who admit to an inchoate alcohol-craving state as their forerunner to a high. Such patients are aware that that just one drink may be sufficient to unleash a high (be it incipient or not), true to the adage that ‘liquor is quicker’.

This leads to another diagnostic dilemma – distinguishing true highs from pseudo-highs when bipolar patients are drinking. Many individuals with bipolar disorder describe feeling less inhibited, and more confident, sociable, playful, gregarious, productive and ‘worry free’ when in their cups. Is this a true bipolar high? Or is it a ‘Clayton's high’ – akin to the tonic marketed as ‘the drink you have when not having a drink’ – merely mild intoxication that is no different to the alcohol-induced conviviality experienced by those without a bipolar condition? Even for those bipolar individuals who move through conviviality to being loud and disinhibited, ‘alcohol intoxication’ may be a sufficient explanation without any suggestion of mood elevation. As Seneca observed, ‘Drunkenness is nothing but voluntary madness’.

Generally, however, bipolar patients seem more likely to describe an iterative process – with the highs fuelling alcohol cravings, which, in turn, fuel mood elevation – akin to the known bidirectional links between creativity and highs.

There is a tendency to romanticize bipolar disorder (or at least the bowdlerized version). It is useful, however, to reflect that highs are seductive and attractive to many patients, and that alcohol is a simple and common strategy to induce or advance a high, and so many will raise a glass to the notion. There is also a tendency to romanticize alcohol. As the British statesman and – possibly – bipolar sufferer, Winston Churchill, observed: ‘I have taken more out of alcohol than alcohol has taken out of me’. And Churchill again: ‘… my rule of life prescribed…the drinking of alcohol before, during, after, and if need be during all meals and in the intervals between them’. For the bipolar patient, however, the whole effect of alcohol and the disorder can create mood states greater than the sum of the parts, risking great personal and collateral damage over time.

As she left her consultation, Janet disarmingly smiled at me, raised her hand, and said ‘Cheers’.