Treating the Highs & Lows of Bipolar Adults

Life event
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. (1979) 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 out.

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).

Expressed emotion
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 mania.

Cognitive approaches
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 to mania?

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.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #4
The preceding section contained information about a psycho-social framework for understanding stress vulnerability in bipolar clients.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
How does George define the process of "mood-repair" in bipolar disorder? Record the letter of the correct answer the CEU Answer Booklet.