Bipolar disorders: an integrating approach

INVITED EDITORIAL

Bipolar disorders: an integrating approach

Ricardo Bernardi

Psychoanalyst. Member and training analyst, Uruguayan Psychoanalytic Association, Montevideo, Uruguay

Continuous advances in mental health require two types of attitude: hope, due to the possibility of new therapeutic benefits, but also care, as a result of the need of critically evaluating new empirical evidence and conceptual changes caused by it. Bipolar disorders are an example of that. If we consider prevalence rates for such disorders, we can see that their values have multiplied over the past years. This new increment is not attributed to an increase in number of cases, but to a change in diagnostic criteria. However, such extension in diagnosis, which may bring therapeutic benefits, also brings new problems. By widening the range of bipolar disorders, there is an overlapping with other disorders and it becomes a problem to differentiate cyclothymic mood fluctuations from affective instability that occurs in personality disorders, in which, in association with mood fluctuation, there are more complex phenomena that cannot be forgotten. In personality disorders, affective instability is often followed by repetition of conflictive situations, in which mood fluctuation does not occur between elation and depression phenomena, but between irritability and anxiety phenomena, which are mingled with environment conflicts. Simplifying diagnosis of these phenomena does not make it simpler to deal with them. Neither it is possible to support that the difference between different disorders is diminished because they respond to the same drugs. Lastly, it is also important to remember the difference between emotional instability observed in a bipolar disorder and mood fluctuations occurring in normal psychic life. It has been stressed that new diagnostic or therapeutic advances lead to exaggerations that result in exaggerated medicalization of human life problems.^*

Mental disorders, due to their causes and/or consequences, are doubtlessly phenomena of a biological, psychological and social nature. Perhaps in past decades there has been an attempt to build global models excessively fast that did not evaluate specific articulations between these levels, reason for which proposed explanations had an eclectic or superficial character.^1-3 However, it is important not to throw the baby out with the bath water. The biopsychosocial perspective, i.e., the need of providing care for the multiple dimensions of human life, is still valid, even if nowadays we can only hope to build temporary and incomplete models.

The problem of periodic mood fluctuations and, more generally, of affective regulation, clearly shows the need of not being carried away by unilateral perspectives. It is not adequate to model the phenomena underlying mood disorders, as if they occurred due to a neuronal engine that is accelerated in mania or delayed in depression. That type of analogy can have a certain heuristic value, but is not enough even to build consistent biological models of the disorder.^† Mood is not an independent phenomenon, but it forms part of vital processes, comprehending all their dimensions, including psychological and interpersonal. Our understanding of such phenomena is still partial. Not only is it difficult to explain the cyclic or periodic character that is in the essence of bipolar disorders, but also the emotional content of polarity. Kraepelin had already stressed the range of symptomatic spectrum of mood fluctuations, as can be observed in mixed states. In addition, categorization of emotions is a complex problem that requires critical examination of the semantic field of commonly used terms.^‡ It is useful to consider the nature of "mood" based on the distinction proposed by Damasio between, on the one hand, "discrete or categorical" emotions (whether they are primitive: fear, joy, anger, etc.; or social: guilt, shame, etc.) and, on the other hand, "background emotions" or "background feelings." Every emotion, and especially these two latter, is part of the organism response to environmental changes,⁶ and every psychic act is an act of affective regulation. Depression or mania are not a mere exaggeration of discrete affections such as sadness, joy or anger: more than categorical emotions, mood can be linked to background emotions and feelings, which are more closely related to the overall status of the organism. But it would also be an error to totally separate these different types of emotions, or imagine background feelings as a purely organic issue. Even if this panorama is sufficiently complex, increasing complexity and introducing the perspective of development and its intersubjective character paradoxically helps clarify our view of those phenomena. Damasio's notion of "background feelings" is similar to that of "vitality affects" or "activation contours" by Daniel Stern,⁷ whose role is relevant in the interactions between the child and its mother, which contribute to processes of affective regulation. Such "activation contours" have a dynamic and amodal nature (that is, they are not related to a specific sensory modality), and reflect the motivational states and organism tensions that we perceive as subjective state. For being amodal, they can play a major role in attunement phenomena between mother and child, and interfere with mutual processes leading to development of affective self-regulation in the child in correspondence with the regulation coming from the mother and to strengthening of the sense of agency and identity. These facts, which were already known based on the works by Winnicott, Bowlby and others, have been recently confirmed by social cognitive neuroscience, which showed that our brain is equipped to articulately process the experiences arising inside our own selves, as well as in the other's self. Perception of the other's internal states not only takes place through external indicators of affects and emotions, but are recognized and categorized more directly through neurobiological processes, such as empathy, associated with the activity of mirror neurons. Mood and affective regulation are, therefore, inseparable from the person's entirety and social life, being part of biological functions related to survival and of development processes of subjectivity and interpersonal relationships.

Such path through field researches in neurosciences reaffirms the validity of biopsychosocial focus. Such focus allows more specific models, such as that proposed by MacKinnon and Pies,⁸ who try to relate these multiple dimensions based on the perspective of development. Those authors suggest that, in order to understand the relation of bipolar disorders and personality disorders, it is necessary to consider how a genetic predisposition to bipolarity can interact with environmental factors in different stages of life. If a child predisposed to a bipolar instability finds a traumatic environment, snowball reactions are produced, which will enhance emotional lack of control and character pathology, favoring the association of a personality disorder with the bipolar disorder. On the other hand, a child with genetic predisposition, but in a favorable environment, develops systems of affective regulation that will restrict the manifestations of bipolar disorder and its effects on personality. It is not possible, according to this model, to analyze bipolar disorder outside the person's global context. An equivalent teaching arises from clinical practice, since it is impossible to properly treat a bipolar patient without considering, along with biological therapies, the patient's personality and his social and family status, not only as to the support the family may provide, but also as to consequences of the disorder in those close to the patient, especially in small children. It is touching to listen to reports by some adults about how their childhood was influenced by the bipolar disorder of one of the parents, above all when the treatment was not followed by psychotherapy or rehabilitation measures for the patient, neither by education or support to the family. The lesson we can learn from the current status of many field researches in neurosciences, as well as clinical practice, is that the best clinical neuroscientist will continue to be a psychiatrist that takes into account the multiple dimensions of human phenomena.

References

• 1. Abroms EM. Beyond eclecticism. Am J Psychiatry. 1983;140(6):740-5.
• 2. Bowden CL. Implications of psychopharmacological studies for the practice of psychoanalysis. J Am Acad Psychoanal. 1992;20(3):477-86.
• 3. Ghaemi N. The concepts of psychiatry. Baltimore: John Hopkins University; 2003.
• 4. Askland K, Parsons M. Towards a biaxial model of "bipolar" affective disorders: spectrum phenotypes as the products of neuroelectrical and neurochemical alterations. J Affect Dis. 2006;94(1-3):15-33.
• 5. Griffiths PE. Emotion and the problem of psychological categories. In: Kazniak AW, editor. Emotions, qualia and consciousness. Singapore, New Jersey, Hong Kong, London: World Scientific; 2001. p. 28-41.
• 6. Damasio AR. The feeling of what happens: body and emotion in the making of consciousness. New York: Harcourt Brace; 1999.
• 7. Stern DN. The interpersonal world of the infant: a view from psychoanalysis and developmental psychology. New York: Basic Books; 1985.
• 8. Mackinnon DF, Pies R. Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum. Bipolar Disord. 2006;8(1):1-14.

*

A conference held in Newcastle, Australia (Inaugural Conference on Disease Mongering, April 11-13, 2006,

http://www.diseasemongering.org) warned about the risk of treating human problems as diseases. Tendency to medicalization of these problems is a result of the desire, both from the pharmaceutical industry and from physicians, public and communication means, to find in medical treatments a solution for many of the setbacks inherent to human life.

†

Askland and Parsons

⁴ show the current difficulty to build a biological model of bipolar disorders integrating molecular, cellular, systematic and behavioral levels. They stress the insufficiency in approaching this issue exclusively based on a neurochemical perspective and suggest inclusion of neuroelectric aspects, and especially pay attention to new knowledge that can arise from interdisciplinary areas.

‡

By examining the contributions of affective neurochemistry, philosophers such as Griffiths

⁵ wondered if the term "emotion" offers a semantic field sufficiently homogeneous to guide research with a certain level of usefulness.

Publication Dates

• Publication in this collection
  31 Mar 2008
• Date of issue
  Dec 2007