Question:
It seems like for most people bi polar is started by stress...and stress makes the symptoms worse...so psychosocial stress can trigger it...?
I have often wondered if almost anyone can become bi polar, given enough stress over a long enough period of time…?
Answer:
During the past several decades, there has been a proliferation of
psychological theories of adult unipolar depression that have been
extended to children (e.g., Abramson, Seligman, & Teasdale, 1978; Beck,
1967; Ferster, 1973; Lewinsohn, 1974; Rehm, 1977; Staats & Heiby, 1985).
Meanwhile, there has been a paucity of psychological theories of bipolar
disorder since Kraepelin (1921) observed mania not only among adults but
also among 3% of his child and adolescent patients.
The apparent assumption of most of the research evaluating the etiology
and treatment of bipolar disorder has been that this is primarily a
biological condition for which primarily biological interventions are
indicated. Biological bias has left the psychological aspects of bipolar
disorder largely unexplored and the biological research poorly
integrated with advances in other areas of investigation (Depue &
Iacono, 1989). Fortunately, a number of investigators have expressed
concern about this state of affairs (e.g., Akiskal, 1986; Bebbington,
1986; Depue & Iacono, 1989; O'Connell, 1986; Perris, 1986; Rehm &
Tyndall, 1993).
The recent developments of psychosocial (Craighead, Miklowitz, Vajk, &
Frank, 1998), cognitive behavioral (fiasco & Rush, 1996), and family
(Miklowitz & Goldstein, 1997) treatments for bipolar disorder are
promising but have focused primarily on enhancement of medication
compliance. They are extensions of treatments developed for unipolar
depression and chronic and severe disorders. These treatments are not
based upon a psychological theory of the development of bipolar disorder
and are not designed as behavioral prevention and change alternatives to
psychoactive substances.
It is the purpose of this paper to suggest an integration of the bipolar
literature on vulnerability factors in childhood and maintenance factors
in adulthood. The guiding theoretical framework for this integration is
Staats' (1975) social behaviorism, later referred to as paradigmatic
(e.g., Staats, 1986) and more recently psychological behaviorism
(Staats, 1996). The theory is an extension of classical and operant
conditioning as well as developmental and cumulative human learning
principles. Each revision of the theory was accompanied with a broader
integration of levels of analysis (e.g., inclusion of organic factors)
and additional behavioral principles (e.g., self-administered
verbal-emotional stimuli that have directive, affective, and reinforcing
effects). Psychological behaviorism (PB) was selected because it has
been shown to have heuristic value for organizing the disparate research
on intelligence (Leduc, Dumais, & Evans, 1990), unipolar depression
(Heiby & Staats, 1990; Staats & Heiby, 1985), anxiety disorders (Hekmat,
1990), and other forms of psychopathology for which there is no
generally accepted theory (Eifert & Evans, 1990; Staats, 1996). Although
the application of PB theory to unipolar depression includes some
mention of bipolar disorder, the utility of the theory for integration
of the bipolar literature has not been evaluated previously.
First, bipolar disorder will be described. Second, a summary of general
PB theory will be presented. Third, the research investigating the
childhood and adult etiology of bipolar disorder will be organized
according to the situational, behavioral, and organic factors proposed
in PB theory. Finally, 15 hypotheses regarding the etiology of bipolar
disorder will be offered and directions for the development of
psychological treatments and subtyping are noted.
Definitions and Phenomenology of Bipolar Disorder
The reliability and utility of the distinction of bipolar from unipolar
depression has been long established (Leonhard, Korff, & Shulz, 1962).
The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV;
APA, 1994) identifies four types of bipolar disorders, all of which
include a history of mania, hypomania, or some admixture of mania and
depression. However, a review (Rehm & Tyndall, 1993) of the unipolar--
bipolar distinction argues that bipolar disorder may involve numerous
subtypes so that a history of mania, as defined in DSM-IV, is
insufficient to specify a taxonomy.
The disparity of the literature on factors related to bipolar disorder
is understandable given the episodic and highly variable characteristics
inherent in the definition of a manic episode itself. The definition of
a manic episode in DSM-IV (APA, 1994) is heterogeneous in terms of the
emotion involved as well as accompanying behaviors. An "elevated,
expansive, or irritable mood" (p. 332) is one necessary criterion. This
criterion permits excessive positive emotions (happiness; euphoria) or
excessive negative emotions (anger; irritability). This inclusion of two
dysfunctional moods under one category is in contrast to the DSM-IV
criteria for a major depressive episode in which one negative emotional
state, dysphoria or loss of pleasure, is the defining dysfunctional mood
characteristic.
Heterogeneity is also illustrated in the DSM-IV criteria indicating that
any three or four of a possible seven remaining symptoms can constitute
the definition of a manic episode. These include inflated self-esteem or
grandiosity, decreased necessary sleep, talkativeness, racing ideas,
distractibility, increased activity, and excessive involvement in
pleasurable activities such that there is a risk for eventual adverse
consequences. For children and adolescents, these behaviors overlap with
normal development at some ages as well as with irritable depression,
conduct disorder, attention-deficit/hyperactivity disorder (APA, 1994),
and schizophrenia (Goodyer, 1992), further obfuscating a clear
identification of bipolar disorder among youth.
The characteristics of manic episodes are a challenge to establish
because they are relatively rare and the onset is difficult to predict.
Prevalence during childhood and adolescence is unknown. Childhood onset
of mania among adults exhibiting bipolar disorder has been estimated to
occur in 20% of cases (Goodwin & Jamison, 1990). Among adults, a 1 month
U. S. adult population prevalence of 0.4% for manic vs. 2.2% for major
depressive episodes has been estimated (Regier et al., 1988). Lifetime
prevalence of a manic episode has been estimated to be 1.6% and of a
depressive episode to be 17.1% (Kessler et al., 1994). Some
epidemiological research has addressed the degree of variability in
expression of the behaviors included in the DSM-IV (APA, 1994)
definition of a manic episode. In their review, Rehm and Tyndall (1993)
indicate that racing ideas may be present in 41% to 100% of manic
episodes, pressured speech in 75% to 100%, delusions in 44% to 75%,
hallucinations in 4% to 40%, heightened activity in 87%, and decreased
sleep in 81%.
It is unknown what percentage of individuals exhibiting manic episodes
express irritability. However, one review suggests anger may be as
common as euphoria (Goodwin & Jamison, 1990) while one study found 8%
exhibit irritability only, 30% euphoria only, and 62% both irritability
and euphoria (Winokur & Tsuang, 1975). The presence of irritability
seems like an important distinction as the affective states of euphoria
and anger are not only subjectively different, but may also emit and
reinforce quite different operant behaviors (e.g., prosocial yet
unproductive gambling versus antisocial dangerousness to others).
Given the stark contrast between the behaviors defining depression and
mania, it is not surprising that research comparing characteristics of
depression between individuals exhibiting unipolar and bipolar
depression has identified a variety of distinctions. This research most
likely involves a subclass of bipolar subjects, as the reported
percentage of bipolar individuals exhibiting a history of depressive
episodes has ranged from 5% to 100% (Goodwin & Jamison, 1990). The
temporal nature of the mood change between depression and mania has been
reported to range from less than 2 days to years (Rehm& Tyndall, 1993).
Compared to unipolar depression, depression in a bipolar disorder has
been shown to differ on the following characteristics: (a) an earlier
average age of onset (Rehm & Tyndall, 1993; Shulman, Tohen, Satlin, &
Mallya, 1992); (b) more sporadic, frequent, and rapid severe mood
changes but with less chronicity (Winokur, Coryell, Keller, Endicott, &
Akiskal, 1993); (c) psychomotor retardation (vs. agitation); and (d)
hypersomnia (vs. hyposomnia) (Rehm & Tyndall, 1993).
The importance of the distinctions between bipolar and unipolar
depression is unclear. Rehm and Tyndall (1993) conclude in their review
of major theories of mood disorders that current approaches are too
narrow and very little is known or theorized about bipolar dis\order
among children and adults. They agreed with a suggestion by Craighead
(1980) two decades ago that future subtyping of mood disorders integrate
biological, environmental, and psychological factors. The following
sections describe a psychological behaviorism theory of bipolar disorder
as one step toward addressing the need to provide a framework to study
the development of and heterogeneity in the expression of mania. The
proposed framework is an extension of the then ...The theories presented in this article, about possible psychosocial
origins of bipolar disorder, ring totally false for me. I'd just like
to lay out my own experience against some points below. I wonder what
other BPers think about the fit of these theories to their own
history.
I suspect that any "psychosocial" correlations are the result of BP
rather than the cause of it.
Briefly, I had my first manic episode (acute, with psychosis) 18 years
ago, at the age of 29. I had 3 further episodes up to 1990 (each one
after stopping lithium). Since then I have been stable on lithium.
Dx BP I; sister, aunt and grandmother have same Dx.
Sure, stress triggers it. But these guys think you learn to be manic!
Mania is a bad habit according to them. Depression is what you
naturally feel after you make an ass of yourself when manic ... sheesh
... Current psychiatric thinking clearly looks at bipolar disorder as a disease
with an organic cause relating to some type of neurohormonal inbalance,
whether it be at the receptor site, or at the neuron production site. The
cause and the treatments are viewed as organic.
