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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.
Prodromes of bipolar relapse
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.
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