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Psychosocial Framework for Bipolar Disorder: Stress Vulnerability
The relationship between life events, long-term difficulties and the onset
of depression has been well established in unipolar depression (e.g. Brown et al., 1987). However, to date, interest in the relationship of life events
to manic depression has received little attention. The few studies that have
considered the role of life events in the onset and recurrence of episodes
have demonstrated variable results.
Studies carried out by Dunner et al. (1979) and Patrick et al. (1978) note
that in the 3-month period before onset, 60% of manic patients had experienced
life events. Glassner et al. also reported a significant increase in
life events prior to relapse though they failed to report the polarity of the
episode. Ambelas (1979) compared a group with bipolar to a group of surgical
controls and found that in the 4-week period before admission for a manic episode
28% of the 67 BIPOLAR group studied reported life events compared to 7% of
surgical controls. In a similar but uncontrolled study Leff et al. (1976) noted
the presence of life events in the month preceding the onset of mania in 28%
of Danish and 29% of English patients. Kennedy et al. (1983) studied a 4-month
period before admission for mania and reported that 85% of the 20 patients
studied had experienced life events. They suggest that the variance apparent
in the studies relating to life, events and bipolar is due to the time period
being studied in most studies.
Overall there is evidence supportive of a link although true prospective studies,
such as those reported in relation to schizophrenia, have yet to be carried
Interrupted development and social withdrawal.
Kahn (1990) refers to the problem of ‘dual vulnerability’. He argues
that labile changes and prodromal symptoms that precede the onset of first
episode in early onset bipolar have a negative impact on the individual’s
interactive style and leads to deficits or delays in interpersonal development.
Goodwin & Jamison (1990) also highlight the interruption or completion
of developmental tasks in early onset bipolar and suggests that these problems
may further exacerbate the occurrence of further episodes. Indeed, it has been
suggested that 50% of individuals with bipolar meet the criteria for personality
disorder (Peselow et al., 1995). Those individuals who later develop bipolar
thus display major vulnerabilities in the interpersonal domain. For many the
realization that the disorder is chronic, recurrent and potentially life-threatening
leads to feelings of denial, anger, hopelessness, anxiety and ambivalence Stigma,
possibly a misperception that accompanies diagnosis, can seriously affect an
individuals self-image such that beliefs about being abnormal could lead to
social withdrawal (Goodwin & Jamison, 1990).
The relationship of specific family attributes such as high communication deviance
and high ‘expressed emotion’ with relapse of schizophrenia is
well documented (e.g. Vaughn et al., 1984). Micklowitz & Goldstein (1990)
reported the same interactive style considered to be predictive in the course
of schizophrenia was also present in bipolar and Micklowitz et al. (1988)
reported a four-fold increase in the probability of a 9-month relapse in
recent onset mania. Priebe et al. (1989) studied expressed emotion (EE) in
relation to lithium prophylaxis to determine whether relatives and patients’ EE
status was related to the course of the illness. They found that patients
living with a high EE relative demonstrated a poorer response during the
3 years preceding interview and an even poorer response in the 9-month follow-up.
Prodromes of bipolar relapse
Investigations into the signs and symptoms leading up to an acute episode of
mania and depression suggested that the period leading up to a depressive
relapse was longer than that for mania (Hopkinson, 1965). However, Molnar (1988)
reported that the manic prodrome was 21 days and significantly longer
than the depressive prodrome of 10 days. They noted that although there was
wide interindividual variation, the symptoms experienced showed consistency
within the same polarity. This finding was further supported by the work
of Smith & Tarrier (1992) who demonstrated that the manic prodrome was
29 days and the depressive prodrome was 19 days. They further noted that
75% of patients could identify a manic prodrome and 85% of patients a depressive
prodrome. Lam & Wong (1995) in a study exploring the relationship between
insight and the ability to cope with prodomal changes found that 25% of patients
could not detect prodomal changes associated with depression. This compared
with only 7.5% who could not detect the prodomal changes associated with
Cognitive theory in manic depressive disorder is remarkably underdeveloped
compared with that for unipolar depression. However, psycho-dynamic theories
have considered mania as protecting the ego from distressing Id impulses,
or that which results from object loss (e.g. Freeman, 1971). In an attempt
to consider the relationship of self esteem in mania, Winters & Neale (1985)
studied matched groups of bipolars, remitted depressives and normals.
A ‘pragmatic inference test’ was used to determine whether self-esteem
influenced inferences about the causes of hypothetical events as a way of
penetrating the supposed ‘mania defense’. They found that a
cognitive schema of low self-worth is evident when remitted bipolars’ inferences
about the causes of failures were explored: they were more likely to consider
negative events as the result of internal personal causes. They identified
that the inferences made were in fact similar to those made by depressives.
Winters & Neale propose that this defense supports the psychodynamic
view, that to reduce unpleasant and painful feelings about the self, individuals
defend; they conclude, however, that it is not known whether this is carried
out at a conscious or unconscious level.
A depressive attributional style has been argued to be a
major component of the vulnerability to depression (e.g. Metalsky et al., 1982).
These studies suggest that non-depressed subjects compared to depressed subjects
use a more biased attributional style, which accredits success to internal
stable global factors and externalizes failure, and that depressed subjects
are attributionally more evenhanded.
It maybe hypothesized that the attributional style operating in bipolars is
similarly evenhanded until possible defenses are elicited following the experience
of life events which switch the attributional style consistent with the manic
or depressed mood? In other words the attributional style may be ‘on
line’ when disordered mood is evident. Work carried out on the development
and maintenance of grandiose delusions suggested that dysfunctional beliefs
about the self would be associated and triggered by perceptions of self related
threat. For example, those with grandiose delusions are more likely to use
repeated fantasy to cope with distressing and unwanted thoughts about perceived
futures (Neale 1988).
How might these findings inform and shape a cognitive model
of mania? Recent work by Teasdale (1997) offers a new perspective with which
to view these findings. Teasdale refers to the notion of modularity put forward
by Foder (1983) which suggests that we have a number of distinct minds which
are specialized and perform distinct functions. Each mind is considered to
be equipped with an evolutionary and developmental history, and at any one
time one of these can be dominant.
I propose that Bipolars, when faced with a situation that is perceived as
threatening or challenging, respond by triggering their appropriate ‘mind
in place’. Work by Parrott & Sabini (1990) studying the effects of
moods and memory recall found a pattern contrary to that predicted by mood
congruence. They found that when the mood was induced by atypical means, e.g.
the weather, succeeding v. s. failing an examination, a pattern of mood incongruent
memory was observed, i.e. the memory response was more likely to be happy when
the mood was depressed and ‘vice versa’ when the mood was happy.
The authors suggest that this phenomena can be explained as ‘mood repair’.
I believe that ‘mood repair’ may form the basis upon which bipolars
switch to their desired mind in place. Why should mood repair in bipolars lead
The switch into mania may involve a process whereby threatening
events lead to cognitive attempts at ‘mood repair’ which, in turn,
lead to the recall of grandiose or fantasorial memories and thus to a ‘mind
in place’ in those individuals who are vulnerable? The following account
suggests that ‘mood repair’ may operate when OK! conditions are
present, and a switch to a ‘mind in place’ could be the manic response.
A patient, who typically books expensive holidays when going ‘high’,
was asked, ‘what led to the idea of the holidays?’ She replied: ‘I
get bored and wish for something exciting to happen. I like to think about
going on holiday-I imagine myself in exotic places; of going places I’ve
seen or heard about: on TV and in magazines--before I know it I’m off
hooking holidays’. These hypotheses and findings offer exciting possibilities
for developing a cognitive approach to the understanding and treatment of bipolar
and require investment in research to parallel the effort made over recent
years in relation to schizophrenia.
- George, Sandra; Towards an Integrated Treatment Approach for Manic Depression;
Journal of Mental Health; Apr98, Vol. 7 Issue 2, p145.
Reflection Exercise #4
The preceding section contained information
about a psycho-social framework for understanding stress vulnerability in bipolar
three case study examples regarding how you might use the content of this section
in your practice.
How does George define the process of "mood-repair" in bipolar disorder? To select and enter your answer go to .