27 Jun Bipolar Disorder
We often say I am not in the mood for going out, or I’m not in the mood to engage in this activity… It takes sometime but we are up and about in a few hours or a couple of days. What do we mean by mood? What happens when these moods last longer? What happens when
this mood is not in our control anymore…?
Mood is a state of emotions resulting from a specific stimulus and is usually temporary. Bipolar disorder falls under the category of mood disorders in the Diagnostic and Statistical Manual of Disorders-5th edition. Mood disorders encompass disorders in which pathological
mood and relative psychomotor disturbances are defining the clinical picture. Such disorders represent a marked deviance from a person’s habitual and regular functioning and often recurin a cyclic or periodic manner. Before we go on to define Bipolar disorder, it is necessary to
get familiar with a few terms.
Mania is an episode or phase (minimum duration is one week) during which an elevated mood is seen, either extreme sense of happiness or an irritable aggressive mood. Delusions or beliefs of greatness or persecution are experienced, there is an increase in goal-directed activity, increased motor activity like over-activeness and restlessness are common. There is an increase in talking and there are racing thoughts which could also lead to speech disturbances. There is a decreased need for sleep and auditory or visual
hallucinations are present. A hypomanic episode is a milder form of symptoms exhibited in mania without perceptual difficulties i.e. no report of delusions or hallucinations and last for at least four consecutive days. A Depressive episode is marked with a persistent low mood, loss of interest in otherwise pleasurable activities, an overarching sadness, reduced desire to work, feelings of hopelessness, helplessness and worthlessness, decreased energy, monotonous tone of speech and a possible suicidal ideation.
A person is said to have bipolar disorder when the experience a manic episode followed by a depressive episode or vice versa. Bipolar disorder’s onset usually is in early adulthood and is more common in females than in males. The DSM-5 has several criteria listed to meet
for a manic or depressive episode. It also mentions the number of minimum criteria to be met in order to provide a diagnosis for bipolar disorder. Research suggests that recurrent episodes are common after the experience of one manic episode and thus medication plays a crucial role in maintaining the mood of the client.
Types of Bipolar disorder and their Symptoms
• Bipolar I disorder
Bipolar I is characterised by the experience of at least one episode of mania preceded or followed by a major depressive episode. The DSM-5 has listed down few features of a manic episode which include an inflated self-esteem, a decreased need for sleep, engaging in activities with a high risk or harmful consequences like shopping sprees and spending money foolishly. Such an episode needs to last for at least one week. A major depressive episode in addition to the features mentioned above include significant loss or increase in weight, insomnia or oversleeping almost every day, fatigue, repetitive thoughts related to death and reduced ability to think or concentrate. This type of bipolar has an equal chance of occurrence in males and females.
• Bipolar II disorder
Bipolar II is diagnosed when there is a presence of a hypomanic episode before or after a major depressive episode. A hypomanic episode does not require hospitalization or a severe impairment in social functioning which may be the case in a manic episode. To add to the features of a depressive episode, anxiety and distress may be a feature in this disorder. This type of Bipolar is more common in females with a higher risk of suicide. It is important to note that while diagnosing . Bipolar II, there has to be no history of a manic episode of the patient.
• Cyclothymic disorder
This is a milder form of Bipolar which comprises of hypomanic symptoms which do not meet the criteria of a hypomanic episode (i.e. lesser symptoms than needed to declare it an episode.) for at least two years and numerous periods with depressive symptoms which do not meet the criteria for a depressive episode. It is also essential for the experience of the symptoms in the two-year frame being present for a majority of the time and not absent for more than a period of two months at a stretch.
Causes of Bipolar
There is no single cause known to elicit bipolar disorder however there is a dominance of biological factors.
• Biological Factors
a. Genetic influences- research suggests an 8-10% chance of having bipolar disorder when a first degree relative has it. Twin studies suggest a high cooccurrence of the disorder in identical twins compared to fraternal twins.
b. Neurochemical factors- the deficiency of serotonin and/or norepinephrine are associated with depressive symptoms and there is evidence for increased activity of these neurotransmitters during a manic episode.
c. Hormonal abnormalities- it is found that cortisol levels are increased during depressive episodes and not elevated during manic phases. It is also hypothesised that abnormalities in thyroid functioning could be associated with mood disturbances.
d. Brain anatomy- PET scans have revealed that reduced blood flow in the left prefrontal cortex of the brain is related to depression, it increases during mania. The basal ganglia and amygdala both associated with regulation of emotions are enlarged in bipolar
• Psychological factors
a. Stressful life events- events like history of child abuse, sexual abuse, domestic violence, loss of a loved one, financial difficulties increase the likelihood of occurrence of bipolar.
b. Poor support- lack of social support from friends, poor family interactions, history of family violence, dysfunctional family interactions could all play a role in developing bipolar disorder
c. Personality factors- research suggests that the personality trait of neuroticism is associated with depressive and manic symptoms. Persons with a pessimistic attributional style are also likely to develop bipolar.
How to identify the need for Counselling?
While psychopharmacology or medication is the first line of treatment for bipolar disorder, therapy and counselling is also necessary for a holistic treatment plan. The prescribed medicines which are usually mood stabilizers or anti-psychotics work directly to control symptoms like the varying moods of mania and depression, they also work on the perceptual difficulties like delusions and hallucinations. However, these drugs have severe side-effects like reduced sexual desire, behavioural difficulties, insomnia, etc which need psychological
attention. There is no one way to identify the need for therapy but a few indicators for considering counselling are:
• Trouble in coming to terms with the diagnosis
• Lack of knowledge about the disorder and treatment
• Difficulties in social functioning
• Lack motivation to undergo and complete the necessary treatment
• Inconsistent relationships and attempts of self-isolation
• Presence of a past traumatic event which needs processing
• Attempts or talks about self-harm
Online therapy makes attending therapy convenient for the client during the hibernation period of the symptoms and episodes. During the depressive phase too when there is a peak in the symptoms and the client does not feel like getting out of bed, they can still manage to attend
therapy from their preferred space.
Reasons for hiring a therapist
Initially the process of being diagnosed with Bipolar can itself be a trigger to manic or depressive episodes and during this time, the role of the therapist is to ground the client, equip them with strategies like relaxation and mindfulness that they can practice alongside the
medication. Since there may be a detachment from reality, it is also essential to work on symptom reduction in therapy. A therapist will also help identify the root causes for the disorder in the client and aid in resolving the psychological causes mentioned above. Usually interactions with family members, relative and friends are impaired and require skills trainings which occur in counselling. Therapy sessions work on the social and emotional impairment and rehabilitation of the individual into his/her normal schedule prior to the disorder. Additionally, the motivation to get better and take medicines are also worked on during therapy. Since the recurrence rate of this disorder is high, any stress experienced in life could be a trigger to an episode, therapy helps process each life event and develop coping strategies while keeping the development of symptoms under constant monitoring and prevent them from reaching a severe stage. Self-esteem issues arising due to the disorder can also be addressed by the therapist. A therapist uses evidence-based strategies to help the client and also provide support to the
caregivers and other family members. Research suggests Cognitive Behavioural Therapy (CBT) as one of the most effective therapies with
Bipolar Disorder. The client is taught to identify their thoughts and how they affect their behaviours and feelings, the focus of CBT is on problem-solving, avoiding triggers for relapse and managing symptoms.
What happens in a therapy session?
Based on the phase in therapy, a session structure would differ. Roughly the initial sessions would be the address the emotions of the client related to the diagnosis, discovering the client’s past and identifying possible causal factors, educating the client about the prognosis
and symptoms and most importantly nurture the relationship with trust and empathy. The nature of the symptoms and their severity, the duration of the disorder and subjective feelings are assessed as well. The acceptance and adjustment phase of therapy would include working on the client’s motivation to undergo treatment, symptom reduction and learning self-monitoring strategies. Work with the family is also done during these sessions to foster emotional support to the client. Supportive psychotherapy and brief therapies are also helpful in cases of relapse. Often support groups may also be recommended to make the client realise that they are not alone in their struggle and even for families to ventilate their feelings and share success stories with one another.
The sessions undertaken provide for the initial acceptance of the disorder, they help the client adjust to the changes, re-establish their social relationships, learn behavioural and social skills like relaxation, mindfulness, eating habits and interaction pattern, self-awareness, selfmonitoring and emotional regulation are key takeaways from therapy sessions. Dr. Rego from the American Psychological Association said that a good treatment outcome incorporates not only stabilization of mood episodes but also equipping the client with behavioural and
cognitive skills to become more aware of triggers and manage them effectively.
Ahuja, N. (2011). A Short Textbook of Psychiatry (7th ed., pp. 67-71). New Delhi: Jaypee
Brothers Medical Publisher (P) Ltd.
American Psychiatric Association (Ed.). (2013). Diagnostic and statistical manual of mental
disorders: DSM-5 (5th ed). American Psychiatric Association.
Colom, F., Vieta, E., Martinez, A., Jorquera, A., & Gasto, C. (1998). What is the role of
psychotherapy in the treatment of bipolar disorder?
Hooley, J. M., Butcher, J. N., Nock, M. K., & Mineka, S. (2017). Abnormal psychology (17.
edition, global edition). Pearson.
Lauder, S. D., Berk, M., Castle, D. J., Dodd, S., & Berk, L. (2010). The role of psychotherapy
in bipolar disorder. The Medical Journal of Australia, 193(4), S31.
Melinda. (2018, November 2). Bipolar Disorder Treatment—HelpGuide.org.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s Synopsis of
Psychiatry: Behavioral Sciences/Clinical Psychiatry.
Swartz, H. A., & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A
Review of the Evidence. Focus (American Psychiatric Publishing), 12(3), 251–266.
What to Expect From Psychotherapy for Bipolar Disorder | Psychology Today. (n.d.).
Retrieved April 30, 2020, from https://www.psychologytoday.com/intl/blog/bipolaryou/201304/what-expect-psychotherapy-bipolar-disorder