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Subject PSYCHOLOGY

Paper No and Title Paper No 15: Clinical Psychology

Module No and Title Module No 17: Bipolar Disorder

Module Tag PSY_P15_M17

TABLE OF CONTENTS
1. Learning Outcomes
2. Introduction to bipolar disorder
3. Clinical picture of Bipolar Disorder
3.1 Depressive episode
3.2 Manic episode
3.3 Hypomanic Episode
3.4 Mixed affective episodes
4. Diagnosis
4.1 Diagnostic subtypes of Bipolar disorders
4.1.1 Bipolar I
4.1.2 Bipolar II
4.1.3 Bipolar Not Otherwise Specified (NOS)
4.1.4 Cyclothymia

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4.1.5 Rapid Cycling Bipolar Disorder

4.1.6 Changes in Diagnostic Subgroups in DSM- V
4.2 Difficulties in diagnosing
5. Epidemiology
5.1 Prevalence rates
5.2 Sex differences
5.3 Age of onset
5.4 Differences between urban and rural settings
5.5 Racial differences
5.6 Socio-economic differences
5.7 Cross-cultural differences
6. Etiological approaches to bipolar disorder
6.1 Biological Approaches
6.1.1 Genetics
6.1.2 Neuro-Endocrinological Causes
6.2 Environmental perspectives
6.3 Psychological perspective
6.3.1 Psychodynamic Approach
6.3.2 Behavioural Approach
6.3.3 Learned- Helplessness Theory
6.3.4 Cognitive Theory
7. Treatment
7.1 Biological Treatments- Pharmacological Treatment
7.2 Psychodynamic approach
7.3 Behavioral approach
7.4 Learned helplessness theory
7.5 Cognitive behavioral therapy
8. Summary

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1. Learning Outcomes
After studying this module, you shall be able to

 Know the signs and symptoms of Bipolar Disorder

 Learn about the epidemiology of Bipolar disorder
 Identify the etiological causes of Bipolar Disorder
 Analyze the various treatment approaches to Bipolar Disorder

2. Introduction

Bipolar Disorder

Bipolar Disorder is one of the variants or forms of the broad category of Mood Disorders. Bipolar disorders is
psychological conditions characterized by alternate episodes of extreme emotional experiences of depression or
mania or both. Though the features are varied, the distinguishing feature is an experience of “excessive mood” that
distorts reality and the way the person thinks or functions. It is often accompanied by changes in activity and
movement, energy levels, sleep patterns, appetite and eating patterns, and motivation
Bipolar Disorder also known as Manic-Depressive Disorder or Manic depression or Bipolar- Affective Disorder. The
distress caused due to this illness can lead to anxiety, poor job functioning, disrupted relationships and in some cases
drive the person to commit suicide. But, Bipolar Disorder can be treated and people with this disorder can lead
fulfilled lives with the aid of medicines and ongoing therapy.

3. Clinical Picture (Signs and symptoms)

3.1 Depressive episodes

Depression is a mood state, lasting only a few hours or maybe a few days but not necessarily causing impairment in a
person’s functioning. Though there are different sub-types of depression that come under unipolar depression,
Bipolar Disorder is characterised by Major Depressive Episode.

According to DSM-IV, criteria for a Major Depressive Episode are as follows:

1. The person must experience a depressed/ irritable mood or a loss of interest or pleasure in most/ all activities
for a minimum of 2 weeks.
2. The person must experience at least 4 of the following Criterion symptoms for 2 weeks-
 Appetite disturbance (loss of appetite or over eating)
 Body weight change associated with appetite
 Disturbance in sleeping patterns (insomnia/hypersomnia)
 Psychomotor agitation or retardation
 Decreased energy
 Feelings of triviality or extreme or inappropriate guilt
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 Difficulty in thinking and concentrating

 Recurrent thoughts of death or suicide or attempting suicide

The feelings of sadness, guilt, hopelessness, anger etc experienced by a person during a major depressive phase is not
temporary but rather exists for a long period of time. The person may experience bouts of sadness at different times
during the day and almost every day of the week. These symptoms are persistent and cause remarkable impairment
or distress in daily functioning, jobs and relationships. The person may withdraw from activities or hobbies which
s/he may have previously enjoyed.

3.2 Manic Episodes

Mania refers to a long period of “feeling high”, overly happy or excitable According to DSM IV a manic episode
includes: (1) a distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least
1 week or less if hospitalization is necessary and (2) three or more associated symptoms such as inflated self-esteem
or grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased involvement in
goal directed activity, psychomotor agitation, and excessive involvement in pleasurable but potentially harmful
activities. Severity of disturbance sufficient to impair occupational, social, interpersonal, or personal functioning, or
to necessitate hospitalization to prevent harm to self or others, is a defining criterion. Behaviours exhibited during
this period are characterised by “impulsivity”. The noticeable features of mania also include talking incessantly,
being euphoric, being overly workaholic and enthusiastic about new projects, yet lacking the concentration to
implement them, not being tired or sleepy.

The cognitive symptoms include both psychotic and non-psychotic symptoms. Psychotic symptoms of delusions,
hallucinations, that may be mood congruent (i.e., delusions or hallucinations with content consistent with elevated
mood) or mood incongruent.. As a result, they may feel “out of control” and engage in violent or destructive
behaviours, which necessitate the need for hospitalisation. Non- psychotic symptoms include a flight of ideas
experienced as racing thoughts, lack of concentration, distractibility, confusion and occasionally disorientation. A
defining criterion is whether the severity of the symptoms is suffice to cause social and occupational impairment or
needs hospitalisation. If untreated, the manic episode can go on for 3 to 6 months.

3.3 Hypomanic episodes

Hypomania is a milder form of mania. The criteria for hypomania as described by DSM-IV as follows:

1. A distinct period of abnormally and persistently elevated or expansive or irritable mood lasting at least 4
days with associated symptoms found in mania.
2. Absence of psychotic symptoms like delusions and without symptoms severe enough to cause occupational
or social impairment or hospitalisation.
3. The hypomanic episode must be distinctly different from the person’s usual non-depressed mood and must
be clear change in functioning.

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The hypomanic episode is actually experienced as enjoyable and

interpreted by the patient as a general sense of well-being. They experience increased physical energy or decreased
need for sleep that can actually lead to high productivity, an increase in fluidity and creativity. Bipolar disorder is
found at higher than chance levels among particularly creative people (Andreasen & Canter, 1974). The person often
denies any problem and thus does not seek treatment.

3.4 Mixed affective episodes

According to DSM-IV it consists of at least one Major depressive episode and a manic episode lasting almost every
day during a one-week period. It includes rapidly alternating moods (sadness- irritability- euphoria), accompanied by
symptoms of a manic episode and a major depressive episode. The symptoms often include insomnia, agitation,
appetite disturbances, suicidal tendencies and psychotic features. Patient may have grandiose thoughts or show
impulsive behavior and may show symptoms of guilt or anxiety at the same time. According to DSM-V, a new
specifier, “with mixed features,” has been added that can be applied to episodes of mania or hypomania when
depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar
disorder when features of mania/hypomania are present.

A mixed episode is a severe form of the bipolar disorder and causes significant functional impairment.

4. Diagnosis

4.1 Diagnostic subgroups of bipolar disorder; the different sub-types of Bipolar Disorder are considered part
of Bipolar Spectrum disorders.

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In the DSM system, the history of current and past episodes in taken into consideration for the purpose of diagnosis.
In DSM-IV, substantial changes have been made in the Bipolar Disorders section. Bipolar Disorder is now clearly
separated into different sub-types.

4.1.1 Bipolar-I

The person experiences one or more manic or mixed episodes, usually accompanied by one or more Major
Depressive episode. DSM-IV has further categorised Bipolar I based on the “Most Recent episode”. Bipolar I, most
recent episode Hypomanic requires at least one major depressive episode and a current or most recent hypomanic
episode. In Bipolar I, most recent episode manic, requires at least one major depressive episode and a most recent
manic episode. In bipolar I, most recent episode unspecified, there should be at least one manic or mixed episode and

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a current manic or mixed or hypomanic or major depressive episode

that has not met the full duration criteria at the time of diagnosis. Patients with Bipolar I experience the highest levels
of elevated mood.

4.1.2 Bipolar II

The individual must have had at least one hypomanic episode (but not manic or mixed episode) that should last
minimum of 4 days and one or more Major depressive episode. Bipolar II is generally taken as less severe form of
Bipolar disorder. However, the cumulative effect is no less than that of Bipolar I. Bipolar II has a more chronic
course and is associated with greater episode frequency, comorbidity, suicidal tendency and a longer depressive
episode. It is also difficult to diagnose due to the presence of hypomanic episode which does not actually cause
functional impairment. The predominant polarity of Bipolar II is depression, thus gives an idea as to why the suicidal
rates are high. Bipolar II is not mentioned in ICD 10.

4.1.3 Bipolar Not Otherwise Specified (NOS)

This is diagnosed when it does not fall under any of the categories If a person displays some symptoms of bipolar
disorder but not others, the clinician may diagnose bipolar NOS. The diagnosis of bipolar NOS is indicated when
there is a rapid change (days) between manic and depressive symptoms and can also include recurring episodes
of hypomania. Bipolar NOS may be diagnosed when it is difficult to tell whether bipolar is the primary disorder due
to another general medical condition, such as substance abuse.

4.1.4 Cyclothymia

Cyclothymia is a chronic mood disturbance persistent for at least 2 years (1 year for children and adolescents), that
involves numerous hypomanic episodes and numerous periods of depressed mood, of insufficient severity and
duration to meet criteria for a major depressive or a manic episode. It is often considered as a mild form of Bipolar
disorder with less or no functional impairment social and occupational areas. Another criteria given by DSM V is
that during the 2 year period, the hypomanic and depressive episode have been present for at least half the time and
the individual has not been symptom-free for more than 2 months.

4.1.5 Rapid-Cycling Bipolar Disorder

Cyclicity refers to the length of time between the episodes. It can range from less than 48 hours to many years, thus
showing considerable intra-individual variation and much greater inter-individual variation. Almost 13-20% of
bipolar patients are categorized as “rapid-cycling” patients, described by Goodwin and Jamison in 1990. According
to DSM-IV criteria, the patient must experience at least 4 distinct episodes (depressed or manic) per year. Thus, the
person experiences rapidly-changing mood swings, with severe irritability, impulsivity, anger bursts etc. The
episodes follow a random pattern and do not occur in regular cycles. This has been found to be more common in
females. Goodwin and Jamiason (1990) have defined another extreme or rare form known as “ultra-rapid cycling”,
with four mood episodes within a month. Some rare cases also show several mood switches during the day, on
several days during the week and are termed as “ultradian cycling” patients. For most cases, rapid cycling develops
later in the course of a disorder.

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4.1.6 Changes in Diagnostic sub-groups in DSM V

 For Bipolar II disorder, DSM- IV had excluded the criteria describing “change from depression to
hypomania under anti-depressant treatments.” In DSM-V, it has been changed as an explicit criterion, provided it
persists fully at the syndromal level beyond the physiological effect of the drug.
 Other Specified Bipolar and Related Disorder: The not so well defined group Bipolar NOS in DSM-V
and has been replaced with Other Specified Bipolar and Related Disorder. This diagnosis takes into account people
who have experienced depression before and currently meet all the criteria for hypomania, except the duration. Also,
if the person has too few symptoms to meet bipolar II criteria, but has been symptomatic for more than 4 days may
fall in this category.

4.2 Difficulties in diagnosing

Different co-morbid conditions make the diagnosis of bipolar disorder difficult. Goodwin and Ghaemi (1999) noted
that almost 40% of hospitalisation cases that they had diagnosed as bipolar had been misdiagnosed before.
 Often the acute and first depressive episodes of bipolar disorder are misdiagnosed to be unipolar.
 Hypomania is particularly difficult to distinguish from normal joy or euphoria.
 Severe psychotic symptoms of grandiosity and hallucinations maybe misconstrued as schizophrenia.
 Features of substance abuse may make it difficult to recognise bipolar disorder. This is one of the most
problematic conditions ( Holmes & Zhao, 1997). Since this feature is pretty widespread, and apart from making
diagnosis difficult, it is also associated with worst outcomes ( Strakowski et al., 1998) as they interfere with
treatment adherence and affect brain processes at the neuronal level.
 Personality Disorders are another category of co-morbid conditions. Studies have found particularly high
rates of Cluster B disorders among bipolar patients. (Dunayevich et al., 1996). Such cases often face greater
maladjustment problems and the course of the disorder is relatively more difficult. (Stober et al, 1995)

5. Epidemiology
Epidemiology is defined as the study of the distribution and determinants of diseases in human populations. Two
major epidemiologic studies are the Epidemiologic Catchment Area Study (ECA) (Robins & Regier, 1991) and the
National Comorbidity Study (NCS; Kessler et al., 1994).

5.1 Prevalence rates

The rate of bipolar I disorder is generally about 1% of the population, and 82.9% of the diagnosed cases falling in the
severe category. 12 months prevalence was found to be 2.6% of the adult population (Kessler, Berglund, Demler, Jin,
Walter, 2005). while the National Comorbidity Survey reported a rate of 1.6% (Kessler et al.,1994) Bipolar II
disorder is estimated to affect somewhere between 0.3 and 3.0% of the population, and bipolar spectrum disorders,
depending on how defined, may affect between 3.0 and 6.5% (Angst, 1998)

5.2 Sex differences

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Epidemiologic studies suggest that bipolar-I is almost equally common

in men and women Bipolar I disorder occurs approximately equally in both sexes and bipolar II may be more
commonly seen in women. Weissman et al., 1996), rapid cycling is also more common and severe among female
population.

5.3 Age of onset

A survey of the empirical literature indicates reliable major differences between age of first onset of bipolar
disorders. Considering hospital admissions as a criterion, most bipolar first admissions occur between ages 20 and 29
(Angst et al., 1973; Kessler et al, 2005 ). Data from the five sites of the NIMH Epidemiologic Catchment Area
(ECA) program reveal a median age at onset 19 years for bipolar (Burke et al., 1990).

5.4 Difference between urban and rural settings

The findings so far have been inconclusive. Though data from three ECA sites have shown non-significant increases
of the incidence of mood disorders (both manic and major depressive episodes) in urban areas compared to rural
(Robins et al., 1984), which indicated the possibility of higher prevalence rates of mood disorders in urban areas, but
such differences may involve interactions among region, migration pattern, socioeconomic status, lifestyle,
environment, and other related variables

5.5 Racial differences

Many studies reported higher rates of bipolar disorder in Whites than Blacks (Jaco, 1960; Marquez, Taintor, &
Schwartz, 1985 but the ECA program report no significant difference between Blacks and Whites.

5.6 Socio-economic status differences

Data suggests a higher incidence of bipolar disorder among upper and possibly middle-class individuals (Coryell et
al., 1989; Peterson, 1977; Weissman & Myers, 1978) while NCS data in contrast show that rates of all psychiatric
disorders decline steadily with income and education (Kessler et al., 1994).

5.7 Cross-cultural differences

The United States had the highest lifetime and 12-month prevalence of BPS (4.4%, 2.8%) while India had the lowest
(0.1%, 0.1%). Exceptions were found for Japan, a high income country with very low lifetime and 12-month
prevalence of BPS (0.7%, 0.2%), and Colombia, a low income country with high lifetime prevalence of BPS (2.6%).

6. Etiological approaches

6.1 Biological approaches

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6.1.1 Genetics: genetic factors have been hypothesized to be

responsible for mood disorders, particularly bipolar. The studies used to investigate are of 4 types: family studies,
twin concordance studies, adoption studies and mode of transmission studies.

Family studies: Higher frequency of mood disorders occur among relatives of bipolar probands as compared to
unipolar probands. The number incidences that have been reported among first-degree relatives are approximately
12-22% (Angst, 1996). Family pedigrees also show a significantly higher incidence (approx. 11%) of bipolar
disorders (Winokur et al., 1999). Also unipolar depression is more common in relatives of bipolar subjects, whereas
relatives of unipolar depressives rarely show bipolar disorder.

Twin studies: These studies show that monozygotic or identical twins are more likely to have mood disorders in
common than fraternal or dizygotic twins- thus indicating a strong genetic contribution to vulnerability. A review of
twin literature showed concurrence of bipolar disorder in 72% of patients who are monozygotic twins as opposed to
14% of dizygotic twins.

Adoption studies: Mendlewicz and Rainer (1977) found that significantly more biological parents have bipolar
disorder (31%) as opposed to 12% of adoptive parents. though this study has not been verified by any other credible
research.

Mode of transmission studies: There is high probability of polygenic transmission for bipolar disorders. (Baker,
1971). Lower father-son concurrence indicates an X-linked gen transmission. ( Mendlewicz, Fleiss & Fieve, 1972).
Some linkage studies point at chromosome 11. ( Egeland, 1987)

6.1.2 Neuro-endocrinological causes: The monoamine theories focus on deficiencies of the neuro-chemical
system that focus on catecholamines, norepinephrine, serotonin and dopamine (Schildkraut, 1965) Conversely,
Mania is said to caused due to excess of neurotransmitters. Other research also points at additional neurotransmitters
like acetylecholine and gammaaminobutyric acid (GABA) as being dysfunctional and hence causing depression
while excess of it may cause mania like symptoms.so the fluctuation between excess and deficieny of the
neurotransmitters may play role.

6.2 Environmental perspective

Stress –Diathesis hypothesis suggests that stress along with the biological predisposition is likely to precede
episodes of disorder. Life events appear to trigger the onset. (Jamison,1990). A life event may trigger a mood
episode in a person with a genetic disposition for bipolar disorder. Even without clear genetic factors, altered health
habits, alcohol or drug abuse, or hormonal problems can trigger an episode.
Good social support acts as a mitigating factor in case of difficult life events. Family atmosphere also has a role to
play- highly conflicting and criticising family members increases the probability of relapse.

6.3 Psychological perspectives

There are various theories which describe the proceses involved in the onset of the disorders as well as propound a
way of treatment.

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6.3.1 Psychodynamic approach: According to Freud, depression

results due to loss of an unconscious object thus leading to anger and reproach becoming self-directed. Mania results
when the conflict is the same but the energy is channelled outward. The manic phases would occur as the ego tries to
defend itself against the id’s aggression by using denial-based defense mechanisms. This might account for the
exaggerated self-esteem and grandiose delusions of the manic patient: in order to protect themselves from the
feelings of worthlessness the ego invents a fantasy wherein the person is more successful or powerful than they
really are. Abraham (1949) speculated that mania represents a failure of the defense-mechanism of repression to
restrict self-hatred and guilt arising from the need to give up sexual gratification without gratification. Arieti and
Bemporad (1980) emphasised on the failure to internalise standards as a reason for depression. Individuals who fail
to meet their own unrealistically high standards are also prone to depression.

6.3.2 Behavioral approach: cause of disorder is disruption of the response- reinforcement relationship. Charles
ferster (1973) asserted that depression is a “generalised reduction of rates of response to external stimuli”. He drew
analogies with the process of extinction- how major losses in life happen due to losses of important sources of
reinforcement.

6.3.3 Learned Helplessness Theory

Martin Seligman’s theory hypothesised that depressed individuals habitually attribute negative outcomes to internal,
stable and global causes, whereas positive outcomes to external, unstable and specific causes. Thus, the person does
not take any credit for success and attributes it to fate or any other external factor. However, according to Alloy,
Clements and Kolden (1985), attributional s tyle is only a risk factor and not a causative factor.
Seligman’s model also does not differentiate between unipolar and bipolar depression with regard to attributional
style. However some studies (Ivens, 1988) indicate that attributional styles are not significantly different for unipolar
and bipolar patients.

6.3.4 Cognitive theory

Aaron T Beck developed a cognitive theory that initially focused on depression. He asserts that the essential
elements of the disorder are in the form of a cognitive triad of dysfunctional thought patterns. while manic
states occur as the patient denies certain aspects of reality in order to promote or preserve an unrealistic set of
self-perceptions, without person’s direct awareness. And the manic mood state is a superficial one that serves
to cover up underlying depressed thinking. Bipolar patients also voice more hopelessness and have more
suicidal thoughts than clinically normal controls (Rosenhan & Seligman, 1989).

7. Treatment

7.1 Biological treatments- Pharmocological Treatment

Bipolar depression is also a major risk factor for suicide and medication generally leads to side effects. For its
effective treatment, correct diagnosis is imperative. Bipolar disorder is commonly treated with mood stabilizers such
as Lithium and anticonvulsants like divalproex sodium. . Sometimes it is accompanied by administration of
antipsychotics and antidepressants.

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Atypical antipsychotic medications like Olanzapine, Aripiprazole,

Ziprasidone etc are used to treat psychotic symptoms that accompany mania. Antidepressants like Fluoxetine,
Paroxetine or sertraline are used to treat depressive symptoms. To prevent rapid switch from depression to mania,
patients are administered a combination of mood stabiliser/ antipsychotic drug with anti-depressant.

ECT: Electroconvulsive therapy (ECT) may be used to treat the manic or depressive phase of bipolar. ECT uses an
electrical current to cause brief seizure, while the individual is under anesthesia. This is considered the most effective
non-drug treatment for bipolar disorder.

Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain.
This treatment if used more commonly than ECT.

7.2 Psychodynamic approach

This involves Psychoanalysis with an intense, open-ended, uncensored exploration of the person’s deepest desires
which may have been pushed into the unconscious. Results of a study by Gallagher- Thompson and Steffen (1994)
found that brief dynamic therapy is effective in treating depressed family care givers.

7.3 Behavioral approach

The therapeutic approach is based on the causes of loss of reinforcement. Initially, the therapy process was matched
to primary deficit faced by the depressed individual. Later, cognitive models were also developed that found that use
of all three kinds of modules i.e activity increase, interpersonal and cognitive were helpful in relieving the person
regardless of their individual deficits. Lewinsohn also suggested that increased self-awareness can mediate between
reduced reinforcement and depression.

7.4 Learned helplessness theory

No therapy program has been actually developed from this perspective but four basic startegies have been outlined
by Seligman (1981):
 The environment should be manipulated such that it promotes recovery, re-establishment of a sense of
control over daily life.
 Skill training to help the person actualise increased ability to control the environment.
 To help patients replace unrealistic goals with realistic goals by giving a “resignation training”.
 Modifying the attributional style to avoid recurrence of depressive episodes.

7.5 Cognitive behavioral therapy

Cognitive therapy is aimed to identify irrational automatic thoughts and the underlying assumptions and challenge
them. The patients are taught to identify and examine their distorted thoughts and perform a reality-check to make
them accurate. Thus they gain coping strategies while improving skills of awareness, introspection and evaluation.

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Though there is no cure for bipolar disorder, but treatment works for
many people. Treatment works best when it is continuous, rather than on and off. However, mood changes can
happen even when there are no breaks in treatment. Patients should be open with their doctors about treatment.
Talking about how treatment is working can help it be more effective. It may be helpful for people or their family
members to keep a daily chart of mood symptoms, treatments, sleep patterns, and life events. This chart can help
patients and doctors track the illness. Doctors can use the chart to treat the illness most effectively.

8. Summary
 Bipolar Disorder is one of the variants or forms of the broad category of Mood Disorders. It is a serious
mental condition that is characterized by extremities of mood.
 The signs and symptoms are characterized by depressive episodes, manic episodes, hypomanic episodes or
mixed affective symptoms.
 For diagnostic purposes, there are various subtypes of bipolar disorders- Bipolar I, Bipolar II, Bipolar NOS
and Cyclothymia.
 Bipolar disorder has been most often attributed to genetics. But psychological approaches also exist.
 There is no cure for bipolar disorder. However, it can be effectively managed with the help of treatment and
psychotherapy. Patients can lead fulfilling lives even with this disease.

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