Lesson 16

Bipolar and Related Disorders II

Topic 77-81

Topic 77: Suicide

Suicide is defined as an intentioned death, a self-inflicted death in which one makes an

intentional, direct, and conscious effort to end one’s life. Suicide is a very negative outcome of
any mental disorder, particularly depression. It is the act of killing oneself, most often as a result
of depression or other mental illness. Suicide is a step taken to deal with intolerable mental
anguish and pain, fear or despair that overwhelms an individual. Suicide is not officially
classified as a mental disorder, although DSM-5’s framers have proposed that a category called
suicidal behavior disorder be studied for possible inclusion in future revisions of DSM-5.

There could be multiple causes of suicide and it should not be attributed to any one single cause.
It is not necessary that all who die by suicide have been diagnosed with a mental illness or all
having a mental illness end their lives by suicide. People who experience suicidal thoughts
experience tremendous emotional pain and overwhelming feelings of hopelessness, despair, and
helplessness.

Regardless of whether suicidal acts themselves represent a distinct disorder, psychological

dysfunction, a breakdown of coping skills, emotional turmoil, a distorted view of life, usually
plays a role in such acts. Suicidal acts may be connected to recent events or current conditions in
a person’s life. Although such factors may not be the basic motivation for the suicide, they can
precipitate it. Common triggering factors include stressful events, mood and thought changes,
alcohol and other drug use, mental disorders, and modeling.

Suicide is not about a moral weakness or a character flaw. People who considering suicide feel
as if their pain will never end and that suicide is the only way to stop their suffering. Several
Factors can contribute to suicide such as:

• Loss

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 • Addictions
• Childhood trauma or other forms of trauma
• Depression
• Psychotic disorder
• Serious physical illness
• Major life changes

All of the above mentioned can make one feel overwhelmed and unable to cope. It is important
to remember that it isn’t necessarily the nature of the loss or stressor that is as important as the
individual’s experience of these things feeling unbearable. Any intentions, no matter how small,
must not be ignored.

Topic 78: Etiological Factors of Bipolar and Related disorders

There are multiple etiological factors that are attributed to development of bipolar and related
disorders. We will discuss the following in this regard:

Neurobiological and Genetic or Chromosomal Factors:

Bipolar disorder is among the most heritable of disorders. Much of the evidence for this comes
from studies of twins.

Adoption studies also confirm the importance of heritability in bipolar disorder. Bipolar II
disorder is also highly heritable. Genetic models, however, do not explain the timing of manic
symptoms. Other factors likely serve as the immediate triggers of symptoms.

There is a huge amount of interest in finding the specific genes involved in mood disorders
through molecular genetics research. Molecular biologists have identified genes associated with
unipolar depression. Unipolar depression may be tied to chromosomes 1,4,9-14, 17,18,20,21,22
and X. Gene 5-HTTs located at chromosome 17 is associated with unipolar depression as 5-
HTTs is responsible for production of serotonin.

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Depression is also associated with low levels of norepinephrine. Mania is associated with high
levels of norepinephrine and dopamine levels. Mania and depression both are associated with
low serotonin levels. Reward system in brain is believed to guide pleasure, motivation, and
energy. Dopamine plays a major role in the sensitivity of the reward system in the brain, which
is believed to guide pleasure, motivation, and energy in the context of opportunities to obtain
rewards. Some research suggests that diminished function of the dopamine system could help
explain the deficits in pleasure, motivation, and energy in major depressive disorder. Among
people with bipolar disorder, several different drugs that increase dopamine levels have been
found to trigger manic symptoms. One possibility is that dopamine receptors may be overly
sensitive in bipolar disorder.

Endocrinal System is also very important in this regard. Unipolar depression is also associated
with high level of cortisol, released in stress by adrenal gland. Cortisol dysregulation also
predicts a more severe course of mood symptoms over time. Melatonin, also called Dracula
hormone as it gets released only in dark, is also associated with depression. If we talk about
seasonal depression, it is usually seen in areas where there is less sunny and they see dark
weather quite often. One cause may be this; they develop more melatonin which causes
depression.

Topic 79: Psychological Factors

Many different psychological factors may play a role in depressive disorders. The triggers of
depressive episodes in bipolar disorder appear similar to the triggers of major depressive
episodes such as:

• Losses in earlier life

• Negative life events
• Neuroticism
• Negative cognitive styles etc.
• Number of rewards received during life time
• Social rewards (social support)

Cognitive View

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In cognitive theories, negative thoughts and beliefs are seen as major causes of depression.
Pessimistic and self-critical thoughts can torture the person with depression. If you always think
negative, it causes the same emotions in your personality.

Cognitive Triade: (Aaron Beck)

As discussed in etiology of depressive disorder, Aron Beck talks of cognitive Triad. It consists of
three forms of negative thinking towards self, towards others and towards future.

There are also errors in thinking/ logic which cause depression. For instance, some people have
an inclination to develop arbitrary inferences i.e. negative conclusion based on insufficient
evidence. Selectively negative things are filtered from situation ignoring the positive one. In
studies of how people process information, depression is associated with a tendency to stay
focused on negative information once it is initially noticed. For example, if shown pictures of
negative and positive facial expressions, those with depression tend to look at the negative
pictures for longer than they look at the positive pictures. People with depression also tend to
remember more negative than positive information.

Automatic thoughts refer to images or mental activity that occurs as a response to a trigger. They
are automatic and 'pop up' or 'flash' in your mind without conscious thought. People who develop
depression usually experience these negative automatic thoughts.

Topic 80: Psychological Factors

Cognitive View

Irrational Thinking (Albert Ellis):

Ellis believed that a large number of psychological problems are due to patterns of irrational
thought. He proposed that people interpret what is happening around them, that sometimes these
interpretations can cause emotional turmoil. Ellis used to list a number of irrational beliefs that
people can harbor. He later shifted from a cataloguing of specific beliefs to the more general
concept of “demandingness,” that is, the musts or should that people impose on themselves and
on others. Thus, instead of wanting something to be a certain way, feeling disappointed, and then
perhaps engaging in some behavior that might bring about the desired outcome, the person
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demands that it be so. Ellis hypothesized that it is this unrealistic, unproductive demand that
creates the kind of emotional distress and behavioral dysfunction that bring people to therapists.

Learned Helplessness (Seligman)

Postulated by Seligman, learned helplessness refers to the perception, based on past experiences,
that one has no control over one’s reinforcements. People in this state typically accept that bad
things will happen and that they have little control over them. They are unsuccessful in resolving
issues even when there is a potential solution. This thinking leads to negative thinking,
eventually causing depression.

Attribution-Learned helplessness:

Attributions refer to the explanations a person forms about why a stressor has occurred. The
model places emphasis on two key dimensions of attributions.

1. Stable (permanent) versus unstable (temporary) causes

2. Global (relevant to many life domains) versus specific (limited to one area) causes

Following is an example of attribution style:

Event: I failed my test today

Internal External

Stable Unstable Stable Unstable

Global I have a Having argument Written tests If the tests are given
problem with with my sister spoiled are not good after vacation no
test anxiety my whole day way to assess one does better
knowledge

Specifi I just have no I got confused and The professor The professor did
c grasp over forgot as I could not gives difficult not prepare test
subject do first question right tests properly due to his
other engagements

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People with depression attribute present loss of control to some internal cause which is both
global and stable. People whose attributional style leads them to believe that negative life events
are due to stable and global causes are likely to become hopeless and this hopelessness will set
the stage for depression. They may feel helpless to prevent future negative outcomes.

Topic 81: Environmental Causes

Socio-environmental models focus on the role of negative life events, lack of social support, and
family criticism as triggers for episodes but also consider ways in which a person with
depression may elicit negative responses from others. People with less social skill and those who
tend to seek excessive reassurance are at elevated risk for the development of depression. Few of
the environmental factors which play a role in bipolar disorder are as follows:

• Abuse
• Mental stress
• A significant loss
• Some other traumatic event may contribute to or trigger bipolar disorder.

It is always important to see that many people experience such bad socio-environmental
challenges but not all of them develop mental disorders. There is a possibility that those with a
genetic predisposition for bipolar disorder may not have noticeable symptoms until an
environmental factor triggers it.

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