A psychoanalytic interpretation of bipolar disorder

Abstract

The author proposes viewing mania as a form of defense against the state of depression resulting from “narcissistic overidentification with the depressive object” (i.e., the object in relation to which the depressive state developed), rather than as a periodic rebellion against such an internalized object. An account of the analytic psychotherapy of a clinical case of bipolar depression serves to illustrate this point of view, linked to the author’s specific conception of the dynamics of depression.     

Responsiveness to Threat and Incentive in Bipolar Disorder: Relations of the BIS/BAS Scales with Symptoms

Over the past 10 years, theorists have suggested that bipolar disorder symptoms result from increases and decreases in the activity of the Behavioral Activation or Facilitation System (BAS or BFS) and the Behavioral Inhibition System (BIS). These neurobehavioral systems are thought to determine the intensity of affective and behavioral responses to incentives and threats. This study examined cross-sectional and prospective associations of self-reported BIS and BAS with mania and depression in a sample of 59 individuals diagnosed with Bipolar I disorder. Depression was tied to BIS, pointing to the importance of sensitivity to threats in depression. However, links between BIS and depression appeared state-dependent. BAS subscales did not correlate with manic symptoms in a state-dependent manner; however, BAS (total scale and reward responsiveness subscale) predicted relative intensification of manic symptoms over time. Thus, evidence suggests that BAS sensitivity may constitute a vulnerability to mania among persons diagnosed with bipolar disorder. Discussion focuses on the integrative potential of the BIS/BAS constructs for linking psychosocial and biological research on bipolar disorder.     

Religion and spirituality in the context of bipolar disorder: a literature review

Religion and spirituality (R/S) may play an important role for individuals with bipolar disorder (BD) by providing a means of coping with, and an explanatory model for, their disorder. We conducted a systematic review of empirical studies that have explored R/S in individuals with BD or samples that explicitly delineate individuals with BD. Only six studies met our inclusion criteria. Findings from these studies suggest that R/S strategies may be important for some people in the management of BD. Religion and spirituality thus become relevant concerns for a therapeutic regime that seeks to develop wellness within a bio-psycho-social model. However, the limited body of research and methodological shortcomings of existing research make it difficult to draw relevant conclusions about how this might be accomplished. The authors propose a need for longitudinal, prospective, mixed methods research in order to inform evidence-based practice.     

Exploring Behavioral Activation and Inhibition Sensitivities Among College Students at Risk for Bipolar Spectrum Symptomatology

We explored cross-sectionally the roles in bipolar spectrum symptomatology of two broad motivational systems that are thought to control levels of responsiveness to cues of threat and reward, the Behavioral Inhibition System (BIS) and the Behavioral Activation System (BAS). Undergraduate students (n = 357) completed questionnaires regarding (a) bipolar spectrum disorders [the General Behavior Inventory (GBI), a well-established clinical screening measure], (b) current depression and mania symptoms (the Internal State Scale; ISS), and (c) BIS/BAS sensitivities (the BIS/BAS scales). Validated cutoff scores on the GBI were used to identify individuals at risk for a mood disorder. It was hypothesized that, among at-risk respondents, high BAS and low BIS levels would be associated with high current mania ratings, whereas low BAS and high BIS would be associated with high current depression ratings. Multiple regression analyses indicated that, among at-risk individuals (n = 63), BAS accounted for 27% of current mania symptoms but BIS did not contribute. For these individuals, BAS and BIS were both significant and together accounted for 44% of current depressive symptoms.     

Intersectional Identities,Identity Dimensions,and Academic Contingencies of Self-Worth

Many people rely on academic performance as an important part of their self-concept, or have academic contingencies of self-worth. We compared academic contingencies of self-worth in three groups of participants, who varied in their feelings about two minority identities: sexual minority Asian/Pacific Islanders, straight Asian/Pacific Islanders, and sexual minority Whites. Comparing pairs of groups that shared one marginalized social identity, we confirmed our hypothesis that participants’ feelings about their racial identity related to contingent self-worth differently based on their sexuality; in contrast, participants’ feelings about their sexual identity related to contingent self-worth in the same way regardless of race. The group defined by the intersection of two minority social identities (Asian/Pacific Islander and sexual minority) is of particular interest.     

Prospective memory,working memory,planning, and attention in schizophrenia and bipolar disorder: A comparative study

There is a need to study prospective memory (PM) and its relationship with aspects of frontal lobe functioning in schizophrenia and bipolar disorder. The study aims to investigate event‐based (EB) and time‐based (TB) PM functioning in the two groups, and its association with working memory, planning, and attention. A word categorisation task was developed to assess PM functioning among 90 participants (schizophrenia, bipolar disorder, and a control group). Frontal lobe functioning was assessed using Tower of London, N‐Back test, and triads test. Mean comparisons revealed significantly higher impairment in TB PM in comparison to EB PM in both the clinical groups. Significant relationship between PM and frontal lobe impairment was found. Relationship between PM and frontal lobe deficits in the clinical groups emphasises the need to include its assessment at an early stage and to develop PM rehabilitation strategies to improve the quality of living.     

Characterization of facial emotion recognition in bipolar disorder: Focus on emotion mislabelling and neutral expressions

Increasing evidence suggests that facial emotion recognition is impaired in bipolar disorder (BD). However, patient–control differences are small owing to ceiling effects on the tasks used to assess them. The extant literature is also limited by a relative absence of attention towards identifying patterns of emotion misattribution or understanding whether neutral faces are mislabelled in the same way as ones displaying emotion. We addressed these limitations by comparing facial emotion recognition performance in BD patients and healthy controls on a novel and challenging task. Thirty-four outpatients with BD I and 32 demographically matched healthy controls completed a facial emotion recognition task requiring the labelling of neutral and emotive faces displayed at low emotional intensities. Results indicated that BD patients were significantly less accurate at labelling faces than healthy controls, particularly if they displayed fear or neutral expressions. There were no between-group differences in response times or patterns of emotion mislabelling, with both groups confusing sad and neutral faces, although BD patients also mislabelled sad faces as angry. Task performance did not significantly correlate with mood symptom severity in the BD group. These findings suggest that facial emotion recognition impairments in BD extend to neutral face recognition. Emotion misattribution occurs in a similar, albeit exaggerated manner in patients with BD compared to healthy controls. Future behavioural and neuroimaging research should reconsider the use of neutral faces as baseline stimuli in their task designs.     

Clinical research on behavioral activation as treatment for post‐traumatic stress disorder: A brief review and meta‐analysis

Behavioral activation (BA), an effective treatment for depression, has recently been receiving attention as a possible intervention for PTSD. BA interventions could be particularly useful in treating underserved populations (i.e., individuals with lower socioeconomic status). A literature search was conducted, which identified seven outcome studies that examined the effectiveness of stand‐alone BA treatment for individuals with PTSD. All studies identified for this brief review demonstrated clinically significant reductions in PTSD symptoms using BA as an intervention. A meta‐analysis of these few studies revealed a nonsignificant effect (Cohen's d = 0.713, p = .512) despite reporting an average symptom reduction of 25.8%. Other studies utilizing BA treatment for PTSD do so in tandem with other interventions and were excluded from analysis. This brief review summarizes the literature on the use of BA as a stand‐alone treatment for PTSD and suggests that future research seek to confirm the usefulness of BA as a potential treatment modality for mental health‐care providers treating individuals with PTSD.     

Revelation,delusion or disillusion: subjective interpretation of religious and spiritual experiences in bipolar disorder

The objective of this study is to explore the interpretation of religious and spiritual experiences during mania, depression and recovery, from the perspective of bipolar clients and to inquire into their expectations of treatment in relation to these experiences. For this purpose, a qualitative pilot study is designed, which includes interviews with 10 outpatients of Altrecht, a Dutch mental health institution. The meaning of religious and spiritual experiences and the question of their authenticity proved to be an important theme for the participants. The support of spirituality for illness management was brought to the fore, as well as the temporary lack of this support during depression by some participants. Participants considered it desirable that more attention be paid to the topic during treatment, and to establish better cooperation between spiritual counsellors of the institution and other professionals. Thus, a more existential or hermeneutical approach towards religious experiences in relation to bipolar disorder would be a desirable contribution to standard treatment. The exact outlines of such an approach demand more empirical research.     

Narrative identity in female patients with remitted bipolar disorder: a negative past and a foreshortened future

The present study examined narrative identity and subjective well-being in outpatients with remitted bipolar disorder (BD) and a healthy control group. Fifteen female outpatients with remitted BD and 15 healthy control participants identified past and future chapters in their life stories, gave their age for the beginning and end of each chapter, rated emotional tone as well as positive and negative self-event connections associated with the chapters, and for future chapters rated the probability of the chapter. The BD patients reported less positive emotional tone and self-event connections for past chapters, but not for future chapters. However, the patients did describe fewer future chapters with shorter temporal projection into the future, and reported lower probability of future chapters. These characteristics of chapters were related to lower subjective well-being. The study suggests that a more negative narrative identity with a foreshortened future perspective may contribute to lower subjective well-being in patients with BD.     

Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder

Hellvin, T., Sundet, K.,Vaskinn, A., Simonsen, C.,Ueland, T., Andreassen, O.A. & Melle, I. (2010). Validation of the Norwegian version of the Social Functioning Scale (SFS) for schizophrenia and bipolar disorder. Scandinavian Journal of Psychology 51, 525–533. Studies of social functioning in severe mental disorders are disadvantaged by the multitude of different assessment instruments in use. The present study aims to establish reliability and validity of the Norwegian version of the Social Functioning Scale (SFS) and to examine social functioning in bipolar disorder (BD) compared to schizophrenia (SZ) and healthy controls (HC). SFS, a 76 item questionnaire divided into seven subscales measuring various aspects of daily life functioning, was administered to samples diagnosed with BD (n = 100) or SZ (n = 100) and to HC (n = 100), recruited from the ongoing Tematic Organized Psychosis (TOP) study. Reliability analyses prove adequate psychometric properties both for the composite full scale score (α: 0.81) as well as for the seven subscale scores (α: 0.60–0.88). Principal component analysis of the subscales confirms a one‐component structure, explaining 59% of the variance. Although significantly correlated with the Global Assessment of Functioning, our results indicate that the SFS measures different aspects of social functioning, is less influenced by demographic and clinical characteristics, but differentiates at the same time significantly BD from SZ. Thus, SFS adds valuable information as a supplement to standard clinician‐rated assessment tools of social functioning, suited both for research and clinical work.     

Patient preferences for medicine administration for acute agitation: results from an internet-based survey of patients diagnosed with bipolar disorder or schizophrenia in two Nordic countries

The objective was to elicit patient preferences for medicine administration method in the management of acute agitation episodes among patients diagnosed with bipolar disorder or schizophrenia. The patients’ experiences of acute agitation episodes and their management of episodes were also explored. Data were collected via an anonymous, internet-based survey of residents in Denmark or Sweden with schizophrenia or bipolar disorder (October 2014 to December 2014). Inclusion criteria were having a diagnosis of schizophrenia or bipolar disorder, and being above 18 years of age. The questionnaire included questions about preferences for medication attributes, experiences with pharmacological treatment for agitation and involvement in treatment plans. A total of 237 diagnosed patients (61 with schizophrenia; 176 with bipolar disorder) completed the questionnaire. Agitation episodes were experienced by 90% of the respondents. In total, 83% of the respondents reported having received treatment with tablets. When patients were presented with the attributes of an inhalation method, respondents stated that the fast onset of action, low risk of adverse reactions and least invasive form of drug delivery were positive attributes of treatment with inhalation. Inhalation is a new delivery route for treatment of acute agitation in patients diagnosed with bipolar disorder or schizophrenia. Inhalation is the preferred treatment method for acute agitation among Danish and Swedish patients with bipolar disorder or schizophrenia.     

Interactional patterns of bipolar patients and their spouses

This study examined the interactional patterns of eight bipolar patients (when manic and in remission) and their spouses by videotaping the couples' interactions and then quantifying those interactions using the Marital Interaction Coding system. These couples' interactions were compared to the interactions of eight happily and eight unhappily married nonbipolar psychiatric control patients and their spouses. The purposes were to determine (a) whether the interactional pattern between bipolar patients and their spouses changes or remains the same when the patient is in a manic vs. a nonmanic state and (b) how the interaction patterns of bipolar patients when manic and nonmanic compare to happily and unhappily married nonbipolar psychiatriccontrol patients. Significant differences in interactions were found between manic and nonmanic states, in addition to significant differences between these patients and the control groups. There were also expected differences between happily and unhappily married psychiatric control groups. Implications are discussed for marital therapy for manies that involves problemsolving and communication training.     

Behavioral Approach System Sensitivity and Risk Taking Interact to Predict Left-Frontal EEG Asymmetry

The Behavioral Approach System (BAS) hypersensitivity theory of bipolar disorder (BD; Alloy & Abramson, 2010; Depue & Iacono, 1989) suggests that hyperreactivity in the BAS results in the extreme fluctuations of mood characteristic of BD. In addition to risk conferred by BAS hypersensitivity, cognitive and personality variables may play a role in determining risk. We evaluated relationships among BAS sensitivity, risk taking, and an electrophysiological correlate of approach motivation, relative left-frontal electroencephalography (EEG) asymmetry. BAS sensitivity moderated the relationship between risk taking and EEG asymmetry. More specifically, individuals who were high in BAS sensitivity showed left-frontal EEG asymmetry regardless of their level of risk-taking behavior. However, among individuals who were moderate in BAS sensitivity, risk taking was positively associated with asymmetry. These findings suggest that cognitive and personality correlates of bipolar risk may evidence unique contributions to a neural measure of trait-approach motivation. Clinical implications of these findings are discussed.     

Reinforcement sensitivity theory and symptoms of personality disorder: Specificity of the BIS in Cluster C and BAS in Cluster B

Gray’s reinforcement sensitivity theory, consisting of the behavioral inhibition (BIS) and behavioral activation (BAS), is frequently used to represent basic dimensions of psychopathology. However, notably few investigations have examined the link between the BIS/BAS and symptoms of personality disorder (PD). Although the Fight-Flight-Freeze System has emerged in the revised model as an important aspect of motivation, the BIS (linked to anxiety) and BAS (linked to impulsivity) have been the primary foci. The current investigation uses a dimensional measure of PD, the schedule for nonadaptive and adaptive personality (SNAP; Clark, 1993) applied to two independent samples of English-speaking participants: undergraduates (n = 276) and clinical patients (n = 47). Results were consistent across both samples, demonstrating that symptoms of Cluster B PDs are indicative of high BAS levels whereas symptoms of Cluster C PDs are characterized by high BIS levels.     

Attentional bias in euthymic bipolar I disorder

Little is known about the nature of the relation between information-processing biases and affective traits in bipolar disorder. The present study was designed to investigate whether attentional biases are evident in persons diagnosed with bipolar disorder when they are in a positive mood state, and whether biases are related to indices of emotion regulation and to prior history of mood episodes. Ninety adults diagnosed with bipolar I disorder and 81 controls with no lifetime mood disorder underwent a positive mood induction and then completed an emotion face dot-probe task; participants in the bipolar disorder group also completed a self-report measure of responses to positive affect. Attentional bias was not related to a diagnosis of bipolar disorder or to symptom severity. Consistent with hypotheses, analyses within the bipolar group indicated that greater dampening of positive affect related to significantly less attention paid to the positively valenced faces. Discussion focuses on the potential role of affective traits in shaping attentional bias in bipolar disorder.     

自恋与行为抑制/激活系统的关系：元分析

运用元分析方法探讨自恋与行为抑制/激活系统的关系。经过文献检索和筛选, 纳入原始文献19篇, 包含25个独立样本, 共7702名被试。根据同质性检验结果, 选用随机效应模型。结果发现, 自恋与行为抑制系统存在中度负相关(r = -0.27, 95% CI为[-0.34, -0.21]), 自恋测量工具在两者间起显著的调节作用; 自恋与行为激活系统存在高度正相关(r = 0.46, 95% CI为[0.40, 0.52]), 被试类型在两者间起显著的调节作用。自恋与行为抑制/激活系统的密切关系支持了自恋的主体性理论和人格强化敏感性理论。