Bipolar Disorder: Biopsychosocial
Etiology and Treatments, and its Place on a Cognitive Spectrum
by Brendan Bombaci
Copyright Brendan
Bombaci 2014
Lulu Press
ISBN:
978-1-312-68030-2
Introduction
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), though new large-sample
examinations of population genetic data on file with the popular genetic
testing organization 23andMe reveal 15 genetic loci associated with increased
risk (Hyde et al. 2016). Also, cultural
consonance research utilizing genetic tests for serotonin receptor
polymorphisms has revealed that depression symptom expression happens most with
one particular polymorphism, but majorly when cultural consonance in family
life is decreased due to having had adverse childhoods as well (Dressler et al.
2016); they actually display increases in
cultural consonance beyond the highest levels of those with the other
polymorphisms who have experienced low childhood adversity levels, revealing a
hypersensitivity and plastic reactiveness to social context (Dressler et al.
2016). The contradiction between the
genetic and sociocultural findings may make Bipolar Disorder (“manic
depression”) a seemingly more confusing or unbelievable diagnosis than depression
alone, given that it is marked by inconsistent bouts of contrasting depressive
lows and euphoric highs. Unless critics know
firsthand the effects of illicit drugs such as cocaine or methamphetamine (Frey
et al. 2006), they may only have a schematic reference to highly caffeinated
states, and not actually to mania – the mind-riding high that lasts hours, days,
weeks, or months at a time depending on how the afflicted person “cycles.” So, mania may not seem like an unmanageable
problem to them. 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 afflicted persons are merely hypersensitive eccentrics.
Indeed, there is evidence that Bipolar
Disorder is more stigmatized than depression (Ellison, Mason, and Scior
2013:818).
Now correlated with risks for and
presence of Bipolar Disorder are 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). This may make the sufferer and those in their
social climate less “culpable” for their own lack of wellbeing, 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.
Prevalence,
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 unintentionally 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 attuned, and thereby
recognize those foods that lift them up, and make a habit of consuming those
more often, as mania is enjoyable in contrast to depression; 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), as their
effects are more overwhelming to those with such genetics. 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.
Culture
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. Luhrmann, Padmavati,
Tharoor, and Osei (2015) have given a term for their own, similar research-based
conclusions, about schizophrenics with auditory hallucinations (a
cross-disorder aspect of psychosis), whereby culture plays a large factor in
the demeanor of such “voices” (and therefore the mood and functionality of the
afflicted): social kindling. In their sampling, South Indian and West African
participants fared much better than Californians – even positively so.
Psychiatrists and academicians
Lawrence Kirmayer and Norman Sartorius would likely explain the more negative
effects, usually seen in afflicted Westerners, 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, Westerners who
experience a condition which includes depression are more likely to be
perceived as best helped by only a creatively supportive 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 (a proxy term for Westernizing,
really), both treatments in conjunction might be the best approach to keeping
the sufferer in between extremes, 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 bipolar states of consciousness, our ancestors may
have become intrigued by the rare band or tribe member that had otherworldly ideations
and/or euphoria or reclusiveness without the likely-practiced consumption of
psychoactive substances amongst others in the tribes (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 well (with the
aforementioned fact that 1.6% of the global population is afflicted, we can assume
that more than 1 in 100 tribe members would be).
The afflicted may have been (and in
some cases still are) 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 as well (Barber and Barber 2006). In this case, supernatural ideologies, part
and parcel of the attractive development of such social institutions, may have originally
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.
Through phylogenetic trees and
linguistic classification (Peoples, Duda, and Marlow 2016), we see animism – a
belief that spirits are in everything – predating even shamanism; and, archaeological
evidence reveals a past where shamanism, in all of its notions of “contracts”
with disembodied beings and altered states of consciousness, is the foundation
of religions (Winkelman and Baker 2010:135-148). Religion may be said, in turn, to be the
foundation of science, given that The Enlightenment which led to the Scientific
Revolution was a philosophical retaliation both borne of and against religious
dogma. Perhaps not so ironically then, first
degree relatives of Bipolar Disorder sufferers tend to find themselves in more scientifically
creative occupations. So, families of
those with Bipolar Disorder 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 can yet be
again, sans stigma) useful in carefully shoring up the ethos of their
disordered relative, and, concomitantly, of their entire family lineage. 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 and endless 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 depths
of depression are reached. The
consequences of these ups and downs are a high price to pay for intense creativity.
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 dietary
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 sanction some legitimate use of such
substances (Rätsch 2005). As mentioned
already, it may be that mentally stable relatives 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/or calculating members of society may be
just on the verge of Bipolar Disorder, or may be, without stigmatizing, autonomically
modeling their thought patterns after those of the suffering.
Hope
and Mindful Caretaking
Firstly, I must say that there is
hope in medicine for the whole Bipolar Disorder spectrum, and, at least for
Westernized people, 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 a manic or nihilistic episode to know
that a state of wellbeing 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) for depression, 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 safely and 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 but one social environment key
to health: 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. Promising research into this has being ongoing
in Europe via the Time to Change Program (Henderson and Thornicroft 2009;
Henderson et al. 2016), 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 results of research where patient
treatments in one study were controlled for in regards to 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 [Bipolar
Disorder] rather than after multiple episodes” (Miklowitz 2009:119, emphases
added). This tells of how the aforementioned social
campaigning is important for another reason: helping a non-stigmatizing public
to recognize early onsets of Bipolar Disorder in each other, and then to give
suggestive warnings. This 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. Even
further effectiveness would come from genetic testing at the doctor’s office
thereafter. No matter
what is done for them, sufferers will be positively 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 (to Westerners) 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 sharpened 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 in either mania or depression do not resonate with their existence as
an "enlightened" being (i.e., depending on which extreme they are in,
many bipolar sufferers, unlike MDD sufferers, will feel at least somewhat 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 in
relationships and productivity that they both toil and despair over.
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