Bipolar Disorder: Biopsychosocial Etiology and Treatments, and its Place on a Cognitive Spectrum
Bipolar Disorder: Biopsychosocial Etiology and Treatments, and its Place on a Cognitive Spectrum
by Brendan Bombaci
Although most people will subscribe
to the brain disease model of schizophrenia
because of its unearthly qualities, many believe that depression is caused solely
by psychosocial stress (Angermeyer and Dietrich 2006:165). To a large extent, it seems they may be right
(Bracken et al. 2012:431, Kohrt et al. 2014, Lee et al. 2007). This makes Bipolar Disorder (“manic
depression”) a seemingly shakier diagnosis than depression alone, given that it
is marked by contrastingly inconsistent bouts of depressive lows, and also by
euphoric highs. Unless they abuse
illicit drugs such as cocaine or methamphetamine (Frey et al. 2006), most
critics as such may only have a schematic reference to highly caffeinated
states, and likely have no experience with mind-riding manic highs that last
days, weeks, or months at a time. They are
likely also influenced by the growing knowledge that Bipolar Disorder sufferers
can be creative geniuses (Jamison 1996).
This may lead to notions that such people are merely hypersensitive
eccentrics. Indeed, there is evidence
that Bipolar Disorder is more stigmatized than depression (Ellison, Mason, and
The truth is that although genes
are not yet definitively associated to Major Depressive Disorder (Lohoff 2010),
five nuclear DNA genes (Muhleisen et al. 2014, Xu et al. 2014), as well as
mitochondrial DNA mutations – possibly increasing oxidative stress leading to
apparent damage to DNA and proteins seen with increased symptom severity (Siwek
et al. 2013:1559,1567), are now correlated with risks for and presence of Bipolar
Disorder. Not only does this news
potentially make their disorder more truly biomedical than depression, mostly freeing
them from blame, it has the potential effect of taking the blame off of their social
environments as well. However, Bipolar
Disorder can be socially exacerbated to the point of episodic psychosis, a
point worth detailed elaboration in this paper. The millions of people worldwide that live
with the neurophysiological rollercoaster of Bipolar Disorder have incredible
fortitude, as they must frequently overcome what could instantaneously force
them into an extremely abject livelihood.
Being subject to the fluctuating feelings of Bipolar Disorder and/or the
delusional and hallucinatory intensity of “Bipolar Disorder –Severe with Psychotic
Features” (APA 1994:351) requires a mostly unrecognized sort of heroism, especially
as many are not “cured” so much as remediated into functionality by medication,
let alone therapy (Basco et al. 2007, Miklowitz 2009). But there is certainly a steadily increasing
degree of hope for the afflicted.
Prevalance, the Addiction Connection, and Family Interaction
Bipolar Disorder occurs in up to
1.6% of the world population (Muhleisen et al. 2014, Xu et al. 2014). “The World Health Organization classifies BD
as one of the top 10 leading causes of the global burden of disease for the age
group of 15-44-year-old people,” and “the heritability estimates for BD range
between 60 and 80%” (Muhleisen et al. 2014).
Some people with Bipolar Disorder also have a variant of the MAOA gene
(Mueller 2007, Preisig et al. 2000), aka “Warrior Gene,” that decreases normal
inhibition of neurotransmitter flooding. This variant is not unique to them, but this
factor alone can explain a lot about manic episodes, as the neurochemical
action of general MAO inhibition is to over-activate endogenous and
dietarily-increased serotonin, melatonin, nor/epinephrine (adrenalin),
phenylethylamine, and dopamine. Through
this, amplification will occur for sensations of euphoria, reward, energy
levels, excitement, physiological hypertension, aggression, and, quite possibly,
hallucinatory altered states. The latter
could occur via either the un/intentional consumption of DMT or 5-MeoDMT [Rätsch
2005:815,852], or increased endogenous levels of the former [Barker,
McIllhenny, and Strassman 2012; Callaway 1988:121]. The counter to these highs will happen when
the neurotransmitters run out or return to baseline. When this rollercoaster ride is the result of
food or substance intake, and given the variety of chemical composition in
Western diets, the symptoms may seem unpredictable. But some sufferers may be more attuned and thereby
recognize those foods that pick them up, and make a habit of consuming them
often, and others may become more attracted and easily addicted to psychoactive
substances such as nicotine (Villégier et al. 2003) and alcohol (Amsterdam et
al. 2006). Substance abuse is a generally
well-known issue with Bipolar Disorder sufferers (Cassidy, Ahearn, and Carroll
2008), and this may be a clue as to why that is.
seems to have a moderating effect on the expressions of Bipolar Disorder. In a meta-analysis of 17 different countries in
various continents, it was found that the maniatrophic
cultures, or “cultures that shape a reward-rich environment by placing a
high value on the individual pursuit of reward and providing opportunities to
do so,” were “correlated with higher prevalence rates of Bipolar I Disorder,”
specifically where either Hofstede’s cultural dimensions of “lower Power Distance
[degree of power inequality] and higher individualism” or “lower Long Term [goal]
Orientation and higher Performance Orientation” occurred (Johnson and Johnson
2014:1114-5). If someone starts showing
signs of Bipolar Disorder and is treated not with patience and carefulness, but
with hyper-attentiveness and either fatalistic concern, judgmentalism, and/or
fear, the patient may have a worse outcome in both the short and long runs. When a loved one behaves as such, with what has
been called high expressed emotion (EE)
– fairly typical in Western countries or developing nations– showing “dramatic expressions of self-sacrifice, extreme
devotion, overprotectiveness, or intrusiveness in the patient’s life” (Watters
2010:152), they embody the hallmarks of what have been generally seen as a
psychotic patient’s inner demons: “demanding, critical, or disparaging voices”
(Watters 2010:153). This risks the
precipitation or exacerbation of psychotic episodes via measurably increasing
the neurophysiological stress levels of the patient.
Psychiatrists and academicians
Lawrence Kirmayer and Norman Sartorius would likely explain these effects
through their seven level framework of psychosomatic and sociosomatic “looping”
wherein, most relatively here – and out of order, (4) “reactions of others to
distress reinforce the experience and expression of distress,” (1) “attention
to sensations increases their salience and intensity, leading to greater and
more focused attention,” (2) “emotional arousal interferes with functioning,
leading to performance decrements, negative self-appraisal, and greater
emotional arousal,” and they end up “catastrophizing or [having] other types of
pathologizing cognitions that undermine coping and elaborate negative
expectations associated with symptoms” (Kirmayer and Sartorius 2007:836). It has been found through a myriad of
studies worldwide that relapse rates for psychotic episodes were three to seven
times greater for patients in families that exhibit high EE (Watters 2010:153), and this looping could be why. The social environment is key. Perhaps intuitively then, those who
experience a condition inclusive of depression in the Western world are more
likely to be perceived as best helped by only psychosocial intervention rather
than antipsychotic medications (Angermeyer and Dietrich 2006:169). The truth is that the condition is both
genetic and psychosocial; so, in a world where the social environment is so
uncertain and globalizing, both treatments in conjunction might be the best approach
to keeping the sufferer balanced, let alone non-psychotic.
Trait Selection and the Disordered Origins of "Visionaries"
It has been pondered why Bipolar
Disorder is expressed in our genes at such a high rate, when fecundity of
sufferers has not been seen as high in the last century. We must turn to biological and cultural anthropology. There is an ongoing and contentious argument
in paleoanthropology circles as to whether or not Neanderthals had symbolic
thought, let alone religion. Something
that separates humans from Neanderthals is the gene NRG3, associated to
schizophrenia (Gibbons 2010:684, Kao et al. 2010). The case may be the same for Bipolar
Disorder, with the NRG1 gene (Jung et al. 2010:1). With the fairly new genetic predisposition to
strange psychotic and/or manic states of consciousness, our ancestors may have
become intrigued by the rare band or tribe member that had otherworldly ideations
and/or euphoria without the likely-practiced consumption of psychoactive
substances (Merlin 2003, Vitebsky 2001:85-87, Winkelman and Baker 2010:126-7). Validation of the honesty in their experiences
and states of consciousness would be made when tribe members witnessed the same
phenomena happening with those rare afflicted members of other groups as
The afflicted may have been seen as
people who are able to perceive facets of reality that others cannot. Because of a shared belief in non-physical
beings between shamanism, religion, and psychosis, and because within those
beliefs “the assumption that certain people are especially likely to receive
supernatural messages from gods or spirits,” it can be argued that “religious
thinking resembles some forms of psychosis” and that “the near [cross-cultural]
universality of specific religious thoughts imparts a potential genetic
etiology upon religion” (Polimeni and Reiss 2002:246, emphasis added). However, religion may have developed for the
purposes of environmental adaptation and group cohesion (Polimeni and Reiss
2002:246) and/or thought compression for moral coding and record keeping to
perpetuate transmission of culture (Barber and Barber 2006). In this case, it would have likely gained
legitimacy through frequently repeated psychotic or manic dramatization, and, bipolar
sufferers may have been so peculiar to have given the reverent a reason to uphold
them and to carry on their genetic material (Polimeni and Reiss 2002:247), perhaps
even preferentially selecting for the disorder phenotypes, explaining why we
see such disorders at a high rate today.
Still, through archaeological evidence we have reconstructed a past
where shamanism, in all of its respects to disembodied beings and altered
states of consciousness, is the foundation of religions (Winkelman and Baker
2010:135-148), which may be said, in turn, to be the foundations of science. Associatively, first degree relatives of Bipolar
Disorder sufferers tend to find themselves in more scientifically creative
occupations, so such families might have had a better understanding of the
world, or higher levels of communication proficiency and persuasiveness, and
therefore better overall attractiveness and fecundity, themselves (Kyaga et al.
2011:378). Perhaps such skills were (and
are) useful in carefully shoring up the ethos of their disordered relative. It is likely the case that every human has
some degree and unique permutation of the mental traits that contribute to
schizophrenia and bipolar disorder both, as there are literally thousands of
common alleles of very small effect that code for increased risk for their
florid, or “full blown,” presentation (Purcell et al. 2009). However, whatever the threshold is between
productivity and functionality, and distraction to the point of detrimental
breakdown, is currently unknown.
Those family members can be seen to
thrive on the creative/”open” as well as “unusual ideas/experiences” end of a theoretical
cognitive spectrum – one now corroborated with DT scans (Jung et al. 2010) and
social science as well as clinical psychiatric research (Nettle 2006) – where poetry
and art are sided with divergent thinking, schizophrenia and affective
disorder, but where “creatives” don’t exhibit the anhedonia and avolition at
the schizophrenic extreme (ibid).
Implications for the afflicted person are that, if they are a Bipolar
Disorder sufferer experiencing psychotic mania,
rather than a catatonic schizophrenic,
they are in just the right position for passion-consumed and uncontrollable artistry
or writing. This may sound like a
blessing, but it won’t be a productive experience for all afflicted people. There are those who feel that
beyond-threshold sufferers are wasting a gift when they get treatment: that
they should instead use their affliction for pinpoint focus on creative works,
revolutionary philosophy, or even spiritual healing. It must be recognized that bouts of mania, even exclusive of psychotic symptoms, can
also lead to self-endangering behaviors such as running away, violent
aggression, and crime (Faedda et al. 2014:319); spending the family savings and
having indiscriminate sex (Boland and Keller 2005:2-3); drug abuse (Miklowitz
2009:114); and even suicide (Miller and Bauer 2014), especially when the lows
of depression are reached. The
consequences of these ups and downs are a high price to pay for intense
Amongst 300,000 people in a recent study
of mental illness and creativity, Bipolar Disorder sufferers do indeed tend to
find more work in creative professions than sufferers of schizophrenia or
unipolar depression (Kyaga et al. 2011:376), but given the fact that most
people in stable professions are stable themselves, these people are likely
sub-threshold or psychiatrically managed.
In regards to feelings that such sufferers should be spiritual guides, i.e.,
it is the case that a myriad of shamans aren’t even psychiatrically abnormal
(Lewis 2003:161-165). In fact, many of
them harness public recognition of the overwhelming power of mental illness by
feigning such illness themselves - not dishonestly but rather for a necessary
cultural drama – and then “overcoming” the affliction/s through a show of shamanic
initiation, in order to have a legitimized niche role in society (ibid:165-172,
Vitebsky 2001:52-92). If they accept the
label of oddity, they are both alienated and upheld, fitting a role that most
have no desire for (as even they will admit to), but one that is verily
respected and has good job security. Their
altered states are likely gained from extreme exertion and/or exogenous
tools. Of the latter, “in those
drug-using societies where adequate data exist, one finds that it is generally
recognized that the shaman is a specific individual whose nervous system and
level of maturity permit him to deal most competently with the realms of
unconscious activity generated by hallucinogenic plant use” (Dobkin de Rios et
al. 1974:152). And indeed, most
societies are, or stem from, those who use such substances (Rätsch 2005). As mentioned already, it may be that the stronger
family members of the afflicted were, and are yet (in modern tribal societies),
those responsible for the enduring practices of shamanism and religion in the
modern day. A Bipolar Disorder sufferer,
out of control or immobile, and a danger to the self and others, is not a
particularly good candidate for the job of independent shaman. Some of our most creative and productive
members of society may be just on the verge of Bipolar Disorder, or may be,
without stigmatizing, modeling their thought patterns after those of the
Hope and Mindful Caretaking
Firstly, I must say that there is
hope in medicine for the whole Bipolar Disorder spectrum, and it should be
considered no matter what social intervention is taking place. Whatever can be done should be done for those,
in situations socially or physiologically debilitating, or life-threatening,
who fight against medication. If such a
a sufferer, in a manic episode, has a hyper-positive sense of self, feeling
“mildly high” about personal attributes such as “being more persuasive,
creative, dynamic, entertaining, outgoing, and so on,” they may show less
response to cognitive therapy (Lam, Wright, and Sham 2005:70), even if their
mania symptom rating is not significantly different from someone who is more
responsive (ibid:76). For them,
medication can certainly get them on the right path. Bipolar tendencies towards extreme
religiosity can also make them feel in depression as though they don’t deserve
treatment, or, in a mixed episode as though they are going against the will of
higher powers, or, in mania, as though they are a sort of god themselves who
would be defiled by or impervious to treatment (Boland and Keller 2005,
Polimeni and Reiss 2002). They likely
will need to be carefully reasoned with.
It can help such a sufferer in either mania or nihilism to know that a
state of well being is something different from what they have known and felt,
something that would offer a challenge to their views about the world, and that
trying it on for size with treatment doesn’t imply permanent commitment.
Antipsychotic medications, unlike
tricyclic and SSRI antidepressants (Bracken et al.: 431), have efficacy well in
contrast to placebo for treating both schizophrenia (Leucht et al. 2012) and
Bipolar Disorder (Cruz et al. 2010, Johnson et al. 2007, Loebel 2014). If the patient or concerned caretaker is
worried about side effects, there is good news.
The newer, “atypical” antipsychotics have less consistent, less
endangering, and less occurring side effects than the older classes (Tandon
2002). Some, such as “mood stabilizers,”
which in many cases are the same class of drugs that treat convulsions, have
been used effectively for many decades, corroborating that there is indeed some
sort of correlation between this psychologically disabling disorder and a
physiologically disabling one.
Medications can have the effect of reducing creativity levels, however
(Kyaga et al. 2011:373). This may just
be a matter of reduction in manic drive to, for example, focus on one creative
task for days on end. Even if they can
be persuaded to take a low dose, where they may still be able to hold onto such
a piece of the disorder they feel is uniquely “them,” it could still be enough
to get them thinking straight, sleeping well, and able to function individually
and cooperatively in society. They may
well grow to like the stability they have when medicated. It must be remembered that, as bipolar
disorder experiences are not just biomedical but rather biopsychosocial, the
patient must be convinced that therapies will benefit them rather than just
make it easier on the caretaker or easier for them to conform to societal
norms. They may feel manipulated
otherwise. Some sufferers of Bipolar
Disorder, who experience psychotic delusions and/or hallucinations without
provocation, may feel that such experience is a normal part of their disordered
mentality. For them, it may be far more
difficult to reduce or disable such effects, but non-oppressive therapeutic
activities have been, and are being, explored for both them and non-psychotic
Bipolar Disorder patients.
For those who do not necessarily
experience psychosis as part of their disorder, nascent research shows that
mindfulness meditation may be therapeutic when in remission (Williams et al.
2007) and when treated with mood stabilizers and/or atypical antipsychotics
(Miklowitz, et al. 2009). Disorder
Specific Psychotherapies (DSPs) such as Cognitive Behavioral Therapy (CBT),
Family-Focused Therapy (FFT), and Interpersonal and Social Rhythm Therapy
(IPSRT) all have proven statistically helpful, though it is not certain which
methods work best in which combinations to make a difference on “the durability
of treatment effects, the relative effects of DSPs on mania versus depression,
or their effects on psychosocial functioning” (Miklowitz 2009:117). Such methods include foci on “early
identification of prodromal symptoms, medication adherence, sleep/wake cycle
stabilization, cognitive restructuring, and family communication styles” as well
as “psychoeducation, including information about medications and side effects,
[...] and community advocacy for the patient” (ibid:117-118). That advocacy is likely another social
environment key: 1 in 5 Bipolar Disorder sufferers across Europe experience
psyche-destructive self-stigma (Brohan et al. 2011), and it is likely that
reductions in societal stigma, enacted through proper illness education and
anti-discrimination legal defense, can reduce self-stigma prevalence. Research into this is being conducted in
Europe (Henderson and Thornicroft 2009), and is crucial because there is
currently no unified model of public stigma towards Bipolar Disorder to be effectively
transformed (Ellison, Mason, and Scior 2013:818).
Though corroboratively concluded to
be mostly effective via randomized controlled trials (Prasko et al. 2013), there
are still confounders with the DSPs that may actually be sharply addressed by
such social reform. “[B]rief
interventions emphasizing medication adherence or early identification and
intervention with prodromal symptoms have significant effects on manic symptoms
but virtually no impact on depression” (Miklowitz 2009:118), which seems to
require intensive long term care with therapies used for schizophrenia or Major
Depressive Disorder. Of all methods
mentioned, CBT seems more published on, and proves to be useful in many cases
(Basco et al. 2007:8-11), however, when research patients in one study were
controlled for the amount of times they had experienced prior episodes, those
with >12 were much harder to treat (Basco et al. 2007:11; Miklowitz
2009:119). CBT may be most promising,
but these findings may “reflect the greater chronicity and cyclicity of BPD
over time” (Basco et al. 2007:11) and may therefore “indicate that intensive [CBT]
should be considered at an early point in the “illness career” of individuals
with BD rather than after multiple episodes” (Miklowitz 2009:119, emphasis
added). This tells of how the aforementioned social
campaigning is important for another reason: helping a non-stigmatizing public
to recognize early the onset of Bipolar Disorder in each other, and then to give
suggestive warnings, could make a dramatic difference in treatment requirements
and outcomes. It could be that someone
who is more educated about the disorder and begins to show signs of it
themselves will not even need such warnings, and will choose to self-admit. No matter what is done for them, sufferers will be altered by
treatment in one way or another – especially by a pharmacological approach –
and most all people have a degree of fear or uncertainty towards major personal
change, even if they are even somewhat aware that it will be for the
better. I have something to say about this.
A Personal Note
The following are suggestions of my own, wrought
from personal experience with Bipolar Disorder. If the patient damns
themselves or feels supernaturally damned for even the slightest of wrongs they
have ever done, or for the slightest imperfections in their being, they can be
reminded that everyone makes mistakes and nobody is perfect, and, that if
humanity, as a collective, or even cosmic powers, did not offer
living things the opportunity to cooperate, let alone be different (rather than
"imperfect") enough to change the status quo, the very idea of beauty
would be narrow, shallow, and vain. There is also promise in the idea
that treatment can help a bipolar sufferer reduce the number of risky or
careless decisions they make, in both action and interaction, therefore offering
a return to balance of inner self and peaceful socialization. If the
sufferer is unreasonably self-loathing beyond this, it can help to let them
know that they are for the most part like everyone else in the world, but with
complications that are helping everyone to know more about where the wonderful
gift we call consciousness even comes from, and that their perspective is
valued whether or not historically it was feared - that social campaigns,
spearheaded by those who empathize, are in the works to help the public understand,
care for, and respect sufferers. This may make them feel useful but
not better; it is probably good to let them know that the
recent and forthcoming advances in medicine and technology can help them to
feel increasingly more stable and comfortable over time as they update their
treatment plans. If, in mania, they feel irrationally empowered,
with seemingly no need for sleep and no limit to their capacity for either
lightning fast interaction or the creative process, justifying through that empowerment
their continued existence as an untreated person, it might be helpful to remind
them of some famous, similarly disordered people existing today who, since
embracing therapy, are self-reportedly far more independent and happy, let
alone socially powerful. After all, both euphoria and augmented social
agency are very enticing for people in manic episodes, and there is promise in
these existing outside of an untreated state. And, no matter what,
it can't hurt to remind a sufferer that self-destructive behaviors do not
resonate with their existence as an "enlightened" being (and
depending on which swing they are on, a bipolar sufferer, unlike a MDD
sufferer, will always feel at least halfway more enlightened than others).
They must remember that they are appreciated for their potential role in
the world, and only a step away from the success they both burn for and despair
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