Dear Dr. Phelps,

Growing up my step-brother and I endured constant screaming rows between my mother and step-father. There was never any predictability.  Dad always late by a couple of hours for any important event and when he finally showed up there would be a screaming match between my parents.

Not only that, but he was a womanizer as well.  Instead of being protected from this, my mother drew me in to her arguments, even getting me on the phone when I was about 12 so that I could swear that she wasn't lying when one of Dad's girlfriends calling saying she was pregnant.

There was also a sick inuendo coming from my step-dad and too much curiousity about my dating.

Does this contribute to my bipolar illness?  My (step) brother is an alcohlic and has wild mood swings.

I am now 54 and when my meds are working I can put my energy into something productive, but when my meds are being regulated a deep rage surfaces and it is really painful.

sincerely,
anne



Dear Anne -- 
You can imagine the difficulty involved in answering this as a research question -- i.e. how would one begin to sort out the relative contribution in an experience like yours of genetic risk for bipolar symptoms versus how much had been contributed by the growing-up experience.  There are some very general ways to approach that question, comparing the "concordance rate" in mono- and dizygotic twins:  meaning that one compares how often one twin gets it versus the other, in "identical twins", who share all their genetic information, versus in "fraternal twins" who share only half.  

In these studies one finds that the "concordance rate" in bipolar disorder (how often does twin B get it if twin A has it) is around 80% in identical twins, but down around 50%, as I recall, for dizygotic twins.  One can infer from these data that, very roughly, subject to many caveats, the relative contribution of genes versus environment is about 80/20.  However, that is an extremely rough way to guess, with so many potentially confounding variables that one really should take this as an educated guess more than a statement.   Here is an example of such a study if you want to pursue that further. 

Meanwhile, the real-life question for you might be "how much can I gain from a really good effort at psychotherapy targeting my experience nowadays (e.g. rage), and looking at my growing up experience to the extent that it seems to inform my current experience?"  Note that's a separate question from "how much can I gain from a really good effort at psychotherapy targeting my rage, using techniques developed specifically for handling rage?"  You may have done both already (the latter would be called "cognitive-behavioral therapy" (CBT) by most, or "anger management").  

However, if you still have mood cycling, most of my patients seem to have great difficulty applying CBT tools when they are in a clear manic or mixed state, or even a severe depressed state; it's like working uphill, way uphill sometimes.  So there the key is to keep trying with medications to get greater mood stability (sorry, I'm sure that one is obvious and surely something you've been working on and are probably still working on).  

Finally, to properly answer your particular question: it does seem fairly clear that early childhood developmental stress is one of the "environmental" factors that can contribute to a genetic susceptibility actually manifesting itself in symptoms.  In other words, "yes". The problem, as you can see, is that "yes" alone doesn't necessarily clearly help you a great deal.  I wouldn't want it to increase your sense of hopelessness, for example, because even though it might sound like it, "yes" doesn't really change your circumstances at all.  The three tools (CBT, or a more "dynamically oriented" psychotherapy as above, or medication efforts) all still stand to help and should be maximized before you turn to "acceptance" methods (another psychotherapy approach, as well as a philosophy/spiritual stance), which also have benefited people a great deal.  

Some one of my patients is going to read this and say to me: but doc', you haven't tried all this with me!  (because sometimes I'll focus on the medication approach first, or refer folks out for the therapy piece)  It's a long, long process.  Good luck to you in it. 

Dr. Phelps