Corzolino attributes their vulnerability to a “disinhibition” of social restraints during manic periods. In other words, they are unable to act with an eye toward future consequences of their behavior.“It’s like the CEO in their brain goes off to Bermuda,” says Cozolino, author of the 2006 book The Neuroscience of Human Relationships: Attachment and the Developing Social Brain. Cozolino defines the brain’s attachment circuitry as the area that helps soothe emotions and tamp down fear. An important part of that is due to the amygdala, an almond-shaped structure deep inside the cerebral hemisphere that regulates fear and panic, and controls the endorphin receptors related to a feeling of well-being.

Numerous MRI studies have confirmed that bipolar patients have significantly greater cerebral blood flow to the left amygdala, suggesting that abnormalities in this brain structure may be implicated in the illness. “We know that in bipolar the homeostatic regulation between the amygdala and other areas of the brain are out of balance,” Cozolino explains. He adds that during sexual arousal and orgasm, biochemicals are activated that generate a feeling of safety and calm.

“It doesn’t last long, it’s not the real thing, but it’s a really pleasant substitute,” says Cozolino. “So think of hypersexuality as an addiction. As an addict you never get enough of a drug....With bipolar disorder you have people who are more vulnerable to using sex as an addiction because they use it for soothing.”

Most bipolar patients with hypersexuality recognize the truth of this statement. “The very thing you think you want—intimacy—is the thing you’re afraid of,” says Karen of Long Island, New York. “You masturbate five or six times a day, you have phone sex, and at some point the sex feels really good and you get addicted to it. It’s a painkiller.” Karen describes herself as a “Miss Goody Two Shoes” before mental illness kicked in when she was still in middle school. Raised in a middle-class family, she establisheda strong spiritual connection to God several years ago. Recently, Karen completed a 12-step treatment program for sex addiction that finally began to address deep healing issues. “When I was younger, the sex was more about getting attention,” Karen says. “I had no boundaries. There was a lot of sexual abuse that happened to me. Although I was not molested, I always felt like a sexually abused person....I felt in some way that because I was compromised emotionally, I could not protect myself. Or else my impulse control was so off.”

In American and Canadian cultures, guilt is typically so attached to sexual activity that it’s sometimes hard to say what truly constitutes hypersexuality. A middle -aged woman with bipolar who lives in Texas is convinced that if it hadn’t been for the influence of her fundamentalist church 20 years ago, she would almost certainly have turned into “a whore.” This is despite the fact that, as she tells it, she’s had sex with only a handful of men. Still, she masturbated regularly, daydreamed about sex “all the time,” and was so wracked with guilt that “I ended up in my clergyman’s office many times, trying to deal with it.” Now 50, this woman has three daughters, all of whom have been diagnosed with bipolar and who suffer from what she refers to as “serious libido issues.” The two older daughters are medicated; the youngest, who is 12, is being treated with diet (no dairy foods) and religious counseling. While doctors sometimes prescribe medications developed for obsessive-compulsive disorder for people with hypersexuality, many patients are dismissive of their effectiveness. Behrman, for example, says he’s been on 37 different drugs and has never found the “hypersexuality medication.”

It is well established that the selective serotonin reuptake inhibitors (SSRIs) are associated with a lowered sex drive. Yet SSRIs are rarely if ever used for bipolar patients, since they could trigger manic episodes. Lithium, however, is well known for its dampening effect on sexuality, and has long been used for its stabilizing effect on the marriages of patients who have bipolar, according to Manic-Depressive Illness by Jamison and Goodwin. “The issue with SRIs is that they can increase libido, and actually cause hypersexuality for people with mania,” explains S. Nassir Ghaemi, MD, director of the Mood Disorders Program at Tufts Medical Center. However, he says, those same SRIs can reduce libido for people who do not have bipolar, noting the subtle distinctions of the use of the same drugs for different patients.

“The mood stabilizers do not cause sexual dysfunction directly, or reduce libido directly,” Ghaemi adds. “By reducing the mania, the hypersexuality is also reduced.” In any case, medication compliance is strongly recommended, along with regular sleep and meals—both are important first steps in getting a person with bipolar stabilized.“No one can grow and become healthy while struggling with that kind of [biochemical] disregulation,” says Cozolino. “Ittakes all their energy just to survive the biological storms.” It is only after a patient has been medically stabilized that therapy can be effectively introduced. “From a psychodynamic point of view, you’re trying to develop close and trusting relationships, to ‘re-parent’ the brain and build the circuitry that’s absent,” Cozolino explains. “And the fact that the brain remains plastic throughout life makes that possible.”

Therapy takes advantage of this plasticity and uses it to develop a new parental relationship between therapist and patient, in effect recreating the missing mother-child bond. That theory borrows from a growing body of research that places primary importance on the mother-child relationship. According to Geller, who has overseen much of that research, the most critical predictor of outcome in children with bipolar disorder is maternal warmth. “[This is true] regardless whether the parents are themselves bipolar or not,” she adds. “In addition to pharmacology, it’s very important to look at mother-child relationships and do what you can to intervene there.”

Recreating this maternal warmth—if possible—may take years, but Cozolino, who is in private practice in Los Angeles, says he has had some success with borderline patients who share a similar psychological makeup with bipolar patients. (In fact, this is just one way of addressing the symptoms via therapy.) The significance of maternal warmth is something that resonates for patients like Karen, who recalls the adolescent girl she once was—the one for whom boys lined up outside the bathroom door, waiting to have sex with her—and sees “an outcast, an untreated bipolar person who’d do anything to get attention.”

Thirty years later, Karen recognizes that her parents always tried to do the right thing, even if that included enrolling her as a 5-year-old child in a Weight Watchers class. “They couldn’t stand that I was overweight,” she says. “The message all my life was you’re not good the way you are.” Even today, food is Karen’s drug of choice. But a careful regimen of medication has helped regulate her rapid-cycling and mood swings, while her religious community has given her a sense of belonging: Karen says she is in full recovery. This doesn’t mean she has become a “good girl,” however.

“You don’t forget what happened to you when you were in that manic phase,” she says, referring to the hypersexuality. “I can’t make it go away now that I’ve found God. I can say no to giving people money. I can say no to sex…I can say no sex until I’m married. But even if I get married to someone tomorrow, am I able to be a demure little housewife? No, I don’t think so.”