Bipolar and related disorders
Bipolar and related disorders are some of the oldest recognised psychiatric
disorders. They are associated with lower life expectancy and suicide.
Characteristics of bipolar and related disorders
These disorders can be separated into two types: unipolar (depression) and
bipolar (mania).
Definitions and characteristics of abnormal affect
This is classified as ‘mood disorders’ in the DSM-5. This is to distinguish them
from the brief feelings of sadness or joy.
-> Emotions are amplified beyond the normal ups and downs in either
extremely negative or positive directions which can persist for long periods of
time and individuals might experience strong feelings of despair and
emptiness or in other instances they may feel anger or Euphoria.
Disorders involving abnormal affect significantly impaired individuals ability to
function normally.
Types: depression (unipolar) and mania (bipolar)
Unipolar depression is one type of affective disorder - the central
characteristics of this type of disorder are the sadness or hopelessness
experienced by the individual for most of the day, on most days.
-> This disorder ranges from mild to moderate or severe.
-> People with this disorder find that they no longer enjoy activities they used
to find pleasurable
-> They may appear angry, withdrawn or tearful and may also experience
changes in appetite and sleep disturbances.
-> Along with these changes come feelings of fatigue and exhaustion and
reduced concentration which make normal functioning difficult.
-> In some cases individuals may experience psychomotor agitation; physical
movements such as pacing or handwringing
Another major disorder in this category is bipolar depression - this disorder
has been known as Manic depression in reference to the Manic symptoms
which make it distinct from unipolar depression.
-> The mood swings of someone with bipolar involve a marked swing between
depressive symptoms in men symptoms.
-> The Manic or depressive Phase may last varying periods of time and may
even be mixed.
Measures: Beck Depression Inventory
One way depression is commonly measured by Health Care professionals is
through psychometric testing. A good example of this is the beck depression
inventory (BDI).
-> This 21 item self-report measure assesses attitudes and symptoms of
depression and is the most widely used tool for detecting depression.
-> The total score across the test is used to determine the severity of the
disorder.
-> Other items related to the known symptoms of depression; feelings of guilt
and hopelessness and psychological symptoms such as fatigue and weight
loss.
Evaluation
-> BDI has high levels of Reliability and validity.
-> it is a quantitative measure so it provides objectivity which could not be
achieved through an unstructured interview
-> since self-report is used there is a risk that validity may be reduced
Explanation of depression
Biological: genetic and neurochemical (Oruc et al. 1997)
First degree relatives such as parents and siblings share 50% of their DNA.
Some mental disorders are thought to have a genetic basis, meaning they can
be transmitted from one generation to the next.
Oruc et al - a sample of participants aged between 31 and 70 years of age
with a diagnosis of bipolar disorder (25 female and 17 male) were drawn from
two psychiatric hospitals.
-> A control group of 40 participants with no personal or family history of
mental health disorder matched for sec and age were included in the study.
-> Sixteen of the bipolar group also had at least one first degree relative who
had been diagnosed with a major affective disorder such as bipolar.
DNA testing was carried out with participants to test for polymorphisms in
serotonin receptors and the serotonin transporters. These were chosen since
alterations in them can lead to disturbance in specific biochemical pathways
with known links to depressive disorders.
Results of the testing showed that there were no significant associations in the
sample. However, serotonin as a neurotransmitter is understood to be
sexually dimorphic (trends for association with both polymorphism in female
participants were observed.)
-> This suggested that these genes could be responsible for an increased risk
of developing bipolar disorder in females only.
Cognitive (Beck, 1979)
Beck believed that the negative views of someone with depression form a
reality for that person. The reason for their behaviour is an underlying process
of incorrect information processing. This is also called cognitive distortion.
-> According to him, this is an automatic process which develops as a result of
earlier life experiences.
Cognitive processes involved in depression can be understood to form a
triad.
-> The individual's view of themselves.
-> The individual perceives the world as presenting them with insurmountable
obstacles to happiness and well-being. They misinterpret external forces as
being against them.
-> A negative view of the future.
Learned helplessness and attribution styles (Seligman et al 1988)
Learned helplessness is behaviour that occurs as a result of a person having
to endure an unpleasant situation, when they perceive the unpleasantness to
be inescapable.
-> In theory, the individual believes they are unable to control the situation and
prevent suffering so they eventually cease to resist it. They believed this might
explain depression - that depression was a direct result of a real or perceived
lack of control over the outcome of one’s situation.
-> This theory is the basis of attributional styles or explanatory style. We
develop particular patterns of thinking towards the world and ourselves.
Seligman investigated how well attributional style could predict depression
symptoms - 39 patients with unipolar depression and 12 patients with bipolar
disorder from the same outpatient clinic participated in the study during a
depressive episode.
-> They included a mix of genders and a mean age of 36 years.
-> They were compared with a control group of 10 participants.
-> They all completed the BDI to assess the severity of symptoms and then
completed an Attributional Style Questionnaire consisting of 12 hypothetical
good and bad events.
-> Both bipolar and unipolar participants were found to have more pessimistic,
negative attributional styles than the non-patient control group.
This suggests that the way we make attributions is an important mechanism
underlying the experience of depression.
Evaluation
-> Seligmann et al. used standardised questionnaires to assess participants.
-> The attributional style questionnaire and BDI are considered to be valid and
reliable measurement tools however the link between BDI and positive
attribution was correlational and it was impossible to determine cause and
effect.
-> The study by Orcu et al. Is limited in terms of its sample size, meaning it is
difficult to generalize from the results.
Genetic studies required for large samples for accurate and valid
analysis.
-> Some participants in the study were still within range for detecting on set for
the bipolar disorder which means the findings may have changed if the
researchers has used an older population so age is an extraneous variable
-> The study collected DNA samples analysed in a laboratory which increases
the validity and removes research bias.
Treatment and management of depression
Biochemical: MAOIs and SSRIs
There are numerous biochemical treatments for depression known as
antidepressant drugs all of which work in slightly different ways.
-> Monoamine oxidase inhibitors World one of the first group of
antidepressants to come into widespread use - they inhibit an enzyme known
as monoamine oxidase which is responsible for breaking down and removing
the neurotransmitters norepinephrine, serotonin and dopamine.
-> The side effects include headaches, drowsiness/ insomnia, nausea,
diarrhoea and constipation. It can also cause patients issues with withdrawal.
Due to this MAOIs tend to be a course of action only for atypical
depression, when other antidepressants or treatments have been
unsuccessful.
Most recently developed anti-depressants include the group known as
selective serotonin reuptake inhibitors.
-> SSRIs act on the neurotransmitter serotonin to stop it being reabsorbed
and broken down once it has crossed a synapse in the brain.
-> These are the most commonly prescribed antidepressants in most
countries.
Both MAOIs and SSRIs are agreed to be more effective treatment for
depression than placebos. There is growing evidence that suggests that the
impact of these drugs on individuals is far more noticeable in patients with
moderate to severe symptoms than mild depression.
Electro-convulsive therapy
ECT is another biological treatment for depression.
-> Usually a last resort.
Dierckx et al. studied over 1000 patients with either unipolar depression or
bipolar depression and found that ECT has similar levels of effectiveness as
CBT, both resulting in 50% remission rate.
-> Since it is administered in small doses, the effects may be short term.
Cognitive restructuring (Beck, 1979)
Cognitive restructuring aims to gain entry into the patient's cognitive
organisation and is essentially a talking therapy based on 121 interactions
between the patient with depression and their therapist.
-> It involves techniques such as questioning and identifying illogical thinking
to determine and change the patient's way of thinking.
This form of therapy begins with explaining the theory of depression to the
patient. Once the individual is able to recognise their own cognitions. The
therapist helps them to understand the link between their thoughts, affect and
behaviour, and how each affects the other.
The patient is directed to catch dysfunctional thoughts outside of therapy and
the purpose of this reality testing is the patience to investigate and begin to
notice negative distortions in thinking for themselves.
-> Cognitive therapy is a well-established way to manage depression.
Wiles et al. showed that it can reduce symptoms of depression for people
who fail to respond to the antidepressants with a sample of 469 individuals
with depression randomly allocated. Those who received therapy were three
times more likely to respond to treatment.
Rational Emotive Behavioural Therapy (REBT) (Ellis, 1962)
Rational emotive behaviour therapy is a psychological approach to treatment
based on the principles of stoicism.
-> stoicism is a philosophy that the individual is not directly affected by outside
things but rather by their own perception of external things.
Albert Ellis places this belief at the core of his theory on how depression
should be recognised and treated - a person becomes depressed as a result
of internal Constructions.
In REBT, the therapist helps individuals to understand the process known as
ABC model. The B stands for one’s beliefs about the event and Ellis argues
that it is how we think about experiences that have the greatest impact on
emotional wellbeing and behavioural outcomes.
The goal of therapies to help individuals create and maintain constructive,
rational patterns of thinking about their lives. This means identifying and
changing thoughts which lead to guilt, self-defeat and self-pity or negative
behaviour.
-> The main way this is achieved is through a process known as ‘disputing’
where the therapist forcefully questions irrational beliefs using a variety of
different methods.
-> The therapist enables the individual to recognise that whatever setback
befalls them they can choose how they think and feel about it.
-> the individuals must begin seeing the consequences (C) they experience
are only partly a result of an activating event (A) and they must accept that
holding on to negative self-defeating beliefs (B) is a destructive tendency.
Lyons and Woods conducted a meta-analysis of 70 REBT outcome studies. A
total of 236 comparisons to baseline, control groups and other
psychotherapies were examined and they found that individuals receiving this
therapy demonstrated significant improvement over baseline measures and
control groups.
-> In comparison, both antidepressants and REBT, are equally effective in
relieving symptoms of depression.
Evaluation
-> Both studies consisted of well-controlled experimental research using large
samples which are highly replicable. They also used control groups which
allows the experimenters to draw valid conclusions about cause and effect.
-> There are serious ethical considerations about the use of antidepressants
and ECT ( this has Side Effects such as memory loss). MAOIs and SSRIs can
have mild, temporary side effects such as headaches aur increase in suicidal
thoughts.
