Justina Žilionytė
Masaryk university, Faculty of Arts: PSX_002 & 006
Semester: autumn 2014
BIPOLAR DISORDER
DEFINITIONS
Depression - is a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of
guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness and poor concentration.
Mania – an extended state of intense, wild elation. People experiencing mania feel intense happiness,
power, invulnerability, and energy. Believing they will succeed at anything they attempt, they may become
involved in wild schemes.
Hypomania – a condition similar to mania but less severe. Hypomanic episodes differ in that they do not
cause significant distress or impair one’s work, family, or social life in an obvious way while manic episodes
do.
Bipolar disorder - a disorder in which a person alternates between periods of euphoric feelings of mania and
periods of depression.
Euthymia - is a normal non-depressed, reasonably positive mood.
Cyclothymia - is a condition in which the patient has recurrent hypomanic episodes and subclinical episodes
of depression.
Bipolar disorder affects an estimated 2-4 % of the U.S. population and is the sixth leading cause of disability
among physical and psychological disorders worldwide. It is associated with heightened risk of financial
problems, relationship dysfunction, substance abuse, homelessness, incarceration, and suicide. Bipolar
disorder is characterized by a lifelong pattern of pathological mood swings ranging from the energized states
which misguided volition and intoxicating euphoria of the manic phases, to the spectrum of depression with
compromised energy, volition, and slowed cognition, concentration and physical activity. The swings
between highs and lows many occur a few days apart or may alternate over a period of years. In bipolar
disorder, periods of depression are usually longer than periods of mania. It is important to understand that
bipolar disorder changes lives. Individuals with bipolar disorder generally have trouble with relationships
across the lifespan. Disrupted life domains in those with bipolar disorder include self-expression, selfimprovement,
family relationships, other social relationships, and work relations. Family members and
caregivers are reported to be considerably burdened, and their burden is frequently associated with the level
of depression in the affected person. Thus, not surprisingly, individuals with bipolar disorder are more likely
to be living alone, yet they are also noted be more likely poor, less educated, or unemployed, compared to
those with major depression or no affective disorder. These disruptions are observed even when the
individuals with bipolar disorder are euthymic at the time of assessment.
CYCLOTHYMIC DISORDER
Cyclothymic disorder is defining as a subtype of bipolar disorder in which people experience a chronic
presentation of low-grade depressive and hypomanic symptoms. It is important to say that cyclothymic
disorder may take on an increasingly important role as the step between nonclinical levels of mood
fluctuation and acute bipolar disorder. Cyclothymia may also be thought as a temperament style, associated
with moodiness and irritability. According to investigators cyclomythic temperament may significantly
increase risk of developing bipolar I or II. Among the affective temperament styles, cyclothymic
temperament is found most often among people who are diagnosed with bipolar spectrum disorder. The
idea of temperament as diathesis is similar to the conceptualization of cyclothymic disorder as a prodrome
or intermediate stage in the developmental of bipolar I or II. However, Cyclothymia can also be considered
a character trait, a personality descriptor without any direct relation to psychopathology.
DIFFERENCES BETWEEN BIPOLAR AND UNIPOLAR DISORDERS
As we know, bipolar disorder is when people sequentially experience periods of mania and depression while
unipolar depression is defining as a major depressive episode that occurs without manic phase that occurs
in the classic form of bipolar disorder. Bipolar depression differs from unipolar depression in being more
characterized by behavioral symptoms such as hypersomnia, lethargy and apathy, in comparison to the
pessimistic thoughts and feelings of worthlessness characterising unipolar depression. One study of 920
patients has suggested that bipolar depression is also associated with a poorer quality of life in the areas of
general health, social functioning, and the physical and emotional domains of their lives comparison to
unipolar patients. Further the recent findings include a study of patients with seasonal, greater psychomotor
agitation and greater social withdrawal than unipolar patients. Also it is important to say that bipolar
depressed patients were less likely to report loss of appetite than unipolar depressed patients, but a
significant minority of bipolar patients reported a co-occurrence of the symptoms of loss of appetite, sleep,
disturbance, loss of energy and low interest that were not found to co-occur in the unipolar group.
DIFFERENCES BETWEEN BIPOLAR I AND BIPOLAR II
People in bipolar I disorder suffer full-blown manic episodes (most commonly interspersed with episodes of
major depression), and people in bipolar II disorder experience depressive episodes and less severe manic
symptoms, classed as hypomanic episodes. Criteria for mania and hypomania have the same symptom
profile (apart from psychotic symptoms, that can occur in mania alone) and differ only in the degree of
severity. According to comparative studies, bipolar disorder I appears to develop less severe symptoms, but
exhibits more of chronic course with more frequent episodes. Moreover, unstable interpersonal
relationships and social adjustment and comorbidity of psychiatric illness were more frequently observed in
bipolar disorder II than in bipolar disorder I. Also, it is important to say that a higher risk of suicide has also
been reported in patients with bipolar disorder II as compared to those with bipolar disorder I. According to
investigators, certain personality traits (neuroticism, extraversion, and openness) have been shown to
significantly impact on the depressive morbidity component of bipolar I disorder. As those with bipolar II
have more depressive illness course than that quantified in bipolar I disorder, examination of associations
between personality traits and affective presentation in this group would be of particular interest for future
research. Hence, compared to bipolar disorder I, bipolar disorder II seems to be a more complicated
condition with regard to clinical course, comorbidity, and familial loading of psychiatric disorders.
SYMPTOMS OF BIPOLAR DISORDER
1. DEPRESSION
Some people with bipolar disorder experience elevated levels of life stress even during asymptomatic
periods. High rates of divorce, unemployment, victimization, and stigmatization are well-documented in
this population. At a basic level, it is important to clarify that people with bipolar disorder differ in how
much depression they experience. It is known that patients with bipolar disorder spend a substantial
proportion of time suffering from syndrome or sub-syndrome depressive symptoms. The outcome of a
12-year prospective longitudinal study, in which 146 patients with bipolar I disorder completed weekly
mood ratings, reported that depressive symptoms were three times more common than manic or
hypomanic symptoms. Major depressive episodes in bipolar disorder are similar to those experienced in
unipolar major depression. Patients suffer depressed mood and experience profound loss of interest in
activities, coupled with other symptoms such as fatigue, weight loss or gain, difficulty sleeping or staying
awake, psychomotor slowing, feelings of worthlessness, excessive guilt and suicidal thoughts or actions.
The risk of suicide is greatly elevated during depression episodes. Approximately 17% of patients with
bipolar I disorder and 24% of patients with bipolar II disorder attempt suicide during course of their
illness. Most suicide attempts and most completed suicides occur in the depressed phase of the illness
and patients with bipolar II disorder are at especially high risk. The standardized morality ratio (SMR) for
suicide in bipolar disorder is estimates to be 15 for men and 22.4 for women.
2. MANIA AND HYPOMANIA
The longitudinal study of bipolar symptomatology mentioned above reported that patients with bipolar
I disorder suffered syndrome or sub-syndrome manic or hypomanic symptoms approximately 9% of the
time over 12 years. For patients with bipolar II disorder, approximately 1% of weeks were spent
hypomanic. It is known that a history of mania is associated with stronger emphasis on goals, even during
euthymic periods. Two studies have found that compared to individuals with no mood disorder,
individuals with a history of mania in remission are more likely to endorse items reflecting perfectionism
and the need to achieve goals on the dysfunctional attitudes scale. People with bipolar disorder seem
to experience greater mood reactivity to environmental circumstances than those without bipolar
disorder do. This reactivity may be more pronounced for positive stimuli. When they are manic, people
with bipolar disorder remember the positive moments in their life much more readily than the negative
moments, and they see themselves much more positively than they do at other times. They show large
increases in confidence after initial success or when they are experiencing hypomanic symptoms. On the
other hand, there are models focused on ‘the manic defense’ in which mania was seen as a flight from
painful feelings. These models predict that mania will occur after negative life events, as a defensive
reaction. Newer cognitive behavioral formulations have propose that people with bipolar disorder might
avoid focusing on threatening information. A key of feature of the manic defense model is the idea that
people with bipolar disorder have high levels of defensiveness against painful thoughts or experiences.
In sum, people with bipolar disorder may not acknowledge negative feelings about the self and may show
more defensive behavior after threat.
3. MIXED STATES
In a full-blown mixed episode, criteria are met for a depressive episode and a manic episode nearly every
day for at least 1 week. However, a mixture of manic and depressed symptoms may occur without
reaching full diagnostic criteria. For example, a patient may have racing thoughts, agitation, overactivity
and flight of ideas but feel worthless, guilty and suicidal. The patients with bipolar I disorder who took
part in the 12-year longitudinal study mentioned previously spent an average 6% of weeks in a mixed
state. For patients with bipolar II disorder the proportion was just over 2%.
THEORIES
1. BEHAVIORAL ACTIVATION SYSTEM (BAS)
A prominent psychological model of bipolar disorder is the BAS deregulation model, variably also termed
the BAS ‘sensitivity’ model. This model expands on cognitive-behavioral conceptualisations of bipolar
disorder, but also attempts to integrate biological vulnerability associated with the condition. Biological
vulnerability is hypothesized to result from deregulation of the BAS – a neurobiological motivational
system operating via dopaminergic pathways that regulates goal-directed approach to potential reward.
Those with bipolar disorder are thought to have a deficit in the serotonergic regulation of such pathways,
rendering them more reactive to cues of reward. The BAS is reactive to influence positive affect, energy,
and attention – with hypo(mania) reflecting extreme sensitivity of this system. BAS functions include a
range of cognitive and affective processes associated with goal-directed behavior.
2. THE COGNITIVE THERAPHY MODEL
Childhood experiences lead to the development of dysfuncional schemas that centre around themes such
as the need to be loved or the need to achieve. Disconfirming experiences or life events later in life, for
example, in the transition from adolescence to adulthood, may lead to "activation" of the dysfunctional
schema in that the person no longer believes that he or she is lovable, or believes that he or she has been a
failure throughout life. The activation of the dysfunctional believes causes the production of negative
automatic thoughts (e.g. “I am unlovable”, “I am failure”, etc.), which in turn case the onset of the relevant
mood such as the depressed state in the vulnarable individual.
3. THE INTERPERSONAL AND SOCIAL RHYTHM THERAPY
The interpersonal and social rhythm therapy approach to bipolar disorder combines the Interpersonal
Psychotherapy approach by Weissman, Klerman for the treatment of unipolar depression, together with a
circadian rhythm model developed by the ITP group at the University of Pittsburg. The IPT approach to
depression was originally developed as a control intervention in a pharmacotherapy trial for unipolar
depression. IPT works with three phases in therapy. The first phase focuses on assessment and formulation.
In addition to history and diagnostic interviewing, IPT includes the so-called Interpersonal Inventory which
is an interview assessment of the social network and social support of the client. The second phase of therapy
selects one of four focus areas on which to base the intervention: Interpersonal Role Disputes (for example:
marital conflict, problems at work); Role Transitions (for example: the transition from adolescence to
adulthood, retirement); Grief (the loss of a significant other); Interpersonal Deficits problems in establishing
and maintaining relationships. The third and final phase of the therapy is the Termination phase in which the
therapist works to establish therapeutic gains and to deal with the issues arising from the ending of therapy.
The second main feature of IPSRT is its focus on social circadian rhythms. The Social Rhythm Metric is
completed as part of the assessment. The SRM seeks to identify specific triggers that are likely to disrupt
normal social rhythms for the individual, to monitor mood, and to monitor social interactions. The plan then
is to regularize social rhythms, especially under circumstances of vulnerability for the individual, or when
certain prodromes or early warning signs of a manic or depressive episode are identified.
TREATMENTS
The established psychological treatments for bipolar disorder as an adjunct to medication are cognitive
behavior therapy (CBT), behavioral family therapy, interpersonal and social rhythm therapy (IPSRT) and
psychoeducation. In terms of formal, the treatments are each highly structured and based on a coherent
stress-vulnerability model. They provide the patient with a personalized overview of their problems and clear
rationale for the intervention, they encourage the independent use skills and knowledge learned and they
promote the patient’s sense of self-efficacy. In terms of continent, they each cover at least four key domains:
psychoeducations about bipolar disorder; stabilization of lifestyle and daily routines, medication adherence
and relapse prevention. Stabilisation of routines is a particular focus given the evidence that disruption in
routine and sleep are key factors preceding mania. Recent reviews of psychological treatment for bipolar
disorder conclude that they lead to sicnificantly fewer relapses when compared to medication and standard
psychiatric treatment alone.
COGNITIVE BEHAVIOURAL THERAPIES
A key component addressed in CBT for bipolar depression is the way that the patients deal with the serious
losses that experience as a consequence of their bipolar disorder. According to Lam, the cognitions of people
with bipolar disorder are likely to centre around themes of loss in realation to the illness, dwelling on feelings
of apathy and indecision, ruminating on poor levels of goal attainment (e.g. “I can’t do it”; “I am no longer
able to”) and making unfavourable comparisons with others. In CBT, the negative automatic thoughts are
addressed using thought diaries. In particular, the patient is encouraged to see the benefits of pleasurable
behaviours that do not ilvolve large increases in activity and are not directed at achieving highly challenging
goals. Having a bath or listening to relaxing music are examples. These adaptations have two functions: first,
to encourage activities that may raise the risk of hypomania, and second to provide evidence against the
dysfunctonial belief that they must become greatly activated and highly successful in order to overcome
their depression. A regular routine of behaviour is also encouraged rather than merely the increase in levels
of activity. Importantly, there is evidence that the prodromes of depression are harder to predict than the
prodromes of mania. CBT for bipolar disorder also focuses on the consequences of bipolar disorder for the
patient’s sense of self. Stigmatisation is a real issue that impacts their social and occupational functioning.
Further, patients may experience guilt and shame concerning behaviours during pats manic episodes and
they may have real losses to grieve owing to the damaging consequences of their illness to work, family and
friendship. Other patients may experience intense feelings of helplessness, disillusionment and hopelessness
associated with depression following their repeated relapses and failed treatments. There is evidence from
mixed sample of patients with schizophrenia and bipolar disorder that negative appraisals of the
consequences of the disorder (e.g. low levels of perceive control of the illness, stigmatization and social
containment) were closely correlated with current symptoms of depression.
OTHER EVIDENCE-BASED PSYCHOLOGICAL TREATMENTS
Several groups have developed programmes of psychoeducation which is usually delivered in a group
discussion format led by a clinical and covers the key areas of medication adherence, stabilization of routines
and relapse prevention. A randomized controlled trial compared 21 sessions of group psychoeducation with
a non-structured group therapy in euthymic patients.
The family focused treatment (FFT) developed by Godlstein and Miklowitz is the most widely research family
intervention. It focuses on improving family communication, problem-solving and coping strategies, and
involves psychoeducation and relapse prevention. Over a 1- year period, the treatment group were less likely
to experience a depressive relapse and showed less depressive symptoms. The effects were partially
mediated by increases in patients’ positive nonverbal interactions during treatment.
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