Bipolar I disorder: abnormal psychology research and clinical perspectives

Bipolar psychiatric disorder (BD) -- which is characterized by "…cycles of depression and mania" -- is a "euphoric, high-energy state" that can produce remarkable bursts of creativity or, on the other hand, can produce erratic behavioral events that are risky and provocative (Gardner, 2011). About 2.4% of the world's population has been diagnosed with bipolar disorder (at one time or another in their lifetime) but the rate in the United States (4.4% of the population) is the highest of any nation (Gardner, p. 1). The lowest rate on record is in India, 0.1%. This paper reviews various aspects and ramifications of the effects of bipolar disorder through nine peer-reviewed research articles.

Bipolar disorder and cigarette smoking

In the journal Bipolar Disorders the authors point out that adults suffering from bipolar disorder are "…two to three times more likely" have begun a serious smoking habit, which is a "devastating addiction" and is very difficult to end for the BD patient (Heffner, et al., 2011). The authors conducted a search for peer-reviewed articles on bipolar disorder and tobacco; they found 262 such articles but only 13 were relevant. In those thirteen articles (most published after 2004) a number of important facts were revealed. For example, adolescents with BD are far more likely to start smoking than the peers who do not have any psychiatric disorder (22% vs. 4%) (Heffner, 440). Eighty percent of those individuals with PD who smoke tobacco continue to smoke for a lifetime while just 40% of those without psychiatric disorders who smoke are users for their lifetimes (Heffner, 440).

As to the reasons why bipolar disorder tends to bring on the smoking habit, and keep it locked in, there are several: a) nicotine has the capacity to "enhance cognitive functioning, including attention"; this is in effect a self-medicating situation; b) medications prescribed for bipolar sufferers ("certain antipsychotics and antiepileptics") tend to "enhance the risk" of becoming a dependent smoker; and c) smoking cessation can cause episodes of mania (Heffner, 442). In fact on page 443 of this article the authors explain that dangerous side effects have been reported when a bipolar patient quits ("seizures, sedation, and worsening of psychiatric symptoms") (Heffner).

Treatment for alcoholism in bipolar disorder patients

Heavy tobacco use isn't the only substance dependence that a bipolar patient may be addicted to. In the peer-reviewed American Journal on Addictions the authors explain that there is a very high "prevalence rate of alcohol abuse/dependency" among bipolar patients, however notwithstanding the epidemiological research that has been conducted, little has been done in terms of studying the results of alcohol treatment programs for bipolar patients (Hall-Flavin, et al., 2010).

Given that the authors assert there is a "high prevalence rate" of alcohol dependency among individuals with bipolar disorder, why are there so few bipolar patients seeking help with alcohol addiction? The authors suggest several reasons, including the fact that there are a limited number of chemical dependency treatment programs. Also, chemical dependency treatment programs generally require "…a degree of behavioral stabilization" and hence, a bipolar person may not qualify because clearly bipolar disorder creates an unstable situation (Hall-Flavin, 41). Moreover, individuals with "undiagnosed, untreated," or only partially treated bipolar symptoms are possibly not as motivated to seek treatment for alcoholic addiction (Hall-Flavin, 41).

It is also possible that notwithstanding dependence on alcohol, a bipolar patient may not even realize that he or she needs treatment; in two surveys (of 3,305 and 7,009 bipolar patients) less than 10% of those responding to the surveys "…even perceived a need for treatment" (Hall-Flavin, 43). The research Hall-Flavin and colleagues conducted shows that women have a higher degree of "vulnerability" to binge drinking than males; and as to why bipolar women need more drinks to reach the level they desire than men, the authors are not certain. But there is evidence that women with bipolar disorder who are also addicted to alcohol have "…higher lifetime rates of posttraumatic stress disorder" than bipolar women that are not alcohol dependent (Hall-Flavin, 43). This could indicate that the increased intake of alcohol in addicted bipolar women may be an attempt to "…numb trauma or decrease anxiety" created by the posttraumatic stress condition (Hall-Flavin, 43).

Marijuana, tobacco, alcohol and the association with bipolar disorder

Heffner and colleagues published another article (a year after the previously reviewed article) that concluded with the report that while smoking cigarettes did not "predict a worse course" of bipolar disorder, smoking has been linked to "…an increased risk of developing alcohol and cannabis use disorders" among adolescents (Heffner, 2012, 99). This research was conducted by the University of Cincinnati on 80 adolescents (under the age of 18) and 81 adults that had been hospitalized for a manic episode, and were surveyed 12 months following the hospitalization.

The hypothesis put forward -- that smoking tobacco would "predict poorer recovery" in the 12 months subsequent to hospitalization and would cause the patient to abuse alcohol and marijuana and might try suicide -- was verified to some degree by the researchers. In the year since initial hospitalization, 28% (20) of the adolescents were hospitalized again and 14% tried suicide (Heffner, 104). But the adolescents who had smoked at the launch of the study were no more likely than those who didn't smoke to "report subsequent hospitalization" (Heffner, 104). As to the adults in this survey, 9 (22%) were hospitalized again and one adult attempted suicide. Meanwhile 13% (9) of the adolescents acquired a cannabis habit in the year after hospitalization and eight of those 9 adolescents also acquired a heavy alcohol consumption habit (Heffner, 104).

So while smoking cigarettes at "baseline" correctly predicted the increased chances of adolescents getting heavily involved in marijuana and alcohol, smoking in this research was not linked to "poorer recovery" per se following the first episode of mania (and hospitalization for that episode) (Heffner, 106).

Suicide and self-mutilation in bipolar disorder

Along with alcohol and tobacco-related dependencies, a scholarly article in the Australian and New Zealand Journal of Psychiatry points out that suicide and self-mutilation are also issues associated with bipolar disorder. Self-mutilation (cutting wrists, arms, legs, etc.) and suicide have been known to be common among people with "borderline personality disorder" (Joyce, et al., 2010). In this article, the authors conducted a study using "adult probands" (probands are persons serving as the beginning point of a research project involving family) that had been previously treated for depression and agreed to participate in a family study of depression (Joyce, 251).

The study continued with a total of 214 probands and 407 "first-degree relatives" -- all of whom were asked to complete a survey (with 240 items utilizing a 5-point Likert scale version of the TCI). Those that completed the surveys were also screened for personality traits and the results of the survey and screenings were entered into a database for analysis. The results showed that for probands that had major depressive issues and had attempted suicide -- compared with probands' relatives with depressive disorders that had not attempted suicide -- their relatives had "…comparable rates of mood disorders and suicide attempts" (Joyce, 254). The same was true for relatives of probands with bipolar disorder that had a history of self-mutilation (compared with relatives of bipolar probands that had not mutilated themselves); the results showed that relatives of bipolar probands that had mutilated themselves also had higher rates of self-mutilation (Joyce, 254). The point here is clearly that depressive disorders like bipolar disorder tend to run in the family, and moreover the negative behaviors associated with bipolar disorder can be seen in close family members of bipolar patients.

Children of bipolar patients are more likely to suffer mental disorders

Along the same theme as the Joyce article, authors Gershon Samuel and Jair Soares report that children of parents with bipolar disorder are "…2.7 times more likely to develop any mental disorder" than are the children of parents who have normal health in a psychological sense (Samuel, et al., 2000). The authors base their assertions on the review of 17 scholarly studies previously published on this subject. They go on to explain that children of bipolar parents are 4 times more likely to "…develop an affective disorder than offspring of normal parents" (Samuel, 465).

In fact children of bipolar parents are known to suffer from "…disruptive behavior disorders, including ADHD, and anxiety disorders" (Samuel, 466). Echoing -- and yet expanding -- the findings of Joyce and colleagues, Samuel reports (466) that bipolar and depressive disorders occurred "…more frequently in the relatives" of bipolar adolescents compared with the relatives of adult probands with bipolar disorders (466).

Criminality, impulsivity, and illnesses associated with bipolar disorder

Criminality is the main topic in another research article in the journal Bipolar Disorders, a piece that points to the fact that criminal behavior by those suffering from bipolar disorder could be related to "substance use disorders" and other conditions related to "impulsivity" (Swann, 2011). In this research, the authors recruited 112 individuals with bipolar disorder, and of those, 29 admitted through a process of self-reporting that they had criminal histories. In comparison to the other 83 individuals that were part of the study, the research showed that the 29 with criminal pasts: a) had "more" antisocial personality disorder (ASPD); b) had less education; c) were more likely to have substance abuse problems; c) had attempted suicide more than the 83 without criminal pasts; and d) were more likely to experience recurrent "mania" (Swann, 173).

The convictions for non-violent crimes committed by bipolar individuals included "…fraud, drug possession or selling, burglary or crimes against property" (Swann, 176). The violent crimes committed by bipolar individuals included "assault and robbery" (Swann, 176). And while the hypothesis (bipolar individuals who exhibit criminal behavior can be linked to substance abuse, personality disorders and other problems related to impulsivity) was partially borne out, the aspect of "impulsivity was not related to conviction history" (Swann, 178).

Bipolar disorder and sustained unemployment

Mark Zimmerman and colleagues published research showing that while the "negative impact of bipolar disorder on occupational functioning is well-known," the facts of "diagnostic comorbidity and sustained unemployment" are not as well-known, hence the research article (Zimmerman, 2010). The authors interviewed 206 patients with bipolar I or bipolar II; the interviews were semi-structured and assessed several variables, such as how much time was missed from work related to the psychiatric problems the individual faced in the past five years. The authors zeroed in on bipolar patients identified with "…comorbid anxiety disorders," a specific group that in the past have been studied primarily on the "efficacy of mood stabilizers for anxiety disorders" and for potential risks that anti-anxiety and antidepressants have on bipolar disorder.

What resulted from the interviews with 206 bipolar patients was the fact that fewer than 20% reported that they actually did not miss any work time because of their bipolar condition (Zimmerman, 720). Of course that means more than eighty percent of the bipolar workers did miss a great deal of time from work. Those bipolar individuals who were unemployed for lengthy periods -- on the whole older people who were prone to bouts of depression -- self-reported "…increased rates of…panic disorder…and a history of alcohol abuse or dependence" (Zimmerman, 720). On page 724 Zimmerman reports that most of the bipolar individuals that were part of this study missed "brief interludes" of work rather than "long periods."

This study leaves some questions unanswered because in the last section the authors doubt the veracity of the self-reporting. To wit, the duration of unemployment reported was based on patients' "…retrospective reports rather than & #8230; observation or reviewing patients employment records" (Zimmerman, 725). It seems a better way to ensure that the employment information is correct would have been to actually access employment records through the human resources offices of the employers that the bipolar patients worked for.

The authors also explain that there have not been any recent studies that examine how accurate self-reports are over a five-year period. In other words, can researchers count on the memories of bipolar patients regarding what they did or did not do as far as employment five years earlier? That would seem to be problematic and it takes away from the apparent quality of this research. Moreover, the authors add that it is possible that "certain forms of psychopathy" can be linked to "biased reporting," and if this is the case it's fair to ask, how valid is the research?

The conclusion to the Zimmerman research may hold the key to the value of this research: it is of "public health significance" to make a determination as to whether present treatments of bipolar disorder patients with anxiety and alcohol problems are "…effective" or not (725). And if treatment strategies are not effective, then clearly new and more effective treatments for bipolar patients with anxiety attacks and alcohol dependency should be developed.

Long-term treatment of bipolar disorder using lithium

One treatment that has shown great potential is lithium. In a peer-reviewed research article in the Canadian Journal of Psychiatry, Cynthia Calkin and colleagues explore the potential effectiveness of lithium therapy for those with bipolar disorder. After outlining the misery that people who are bipolar go through (increased rates of cardiovascular disease, premature death and suicide "completion"), the authors explain that while the "efficacy of lithium" has been projected to be about 75%, when new and current criteria are factored in, lithium is only 30% effective (Calkin, 2012).

One reason the newer criteria reduces the percentages of successful treatment as far as the effectiveness of lithium is concerned, is that the definition of bipolar disorder has changed and evolved. There have been controversies in the past over exactly what constitutes bipolar disorder; the difference between "major depression" and bipolar disorder is tricky, and hence many patients have been misdiagnosed (Calkin, 438). The authors suggest that between ten percent and forty percent of people diagnosed as having bipolar disorder when they do not have that disorder. Still other sources suggest that on the other hand, fifty-seven percent of patients that have been diagnosed with "postpartum depression" and 80% of patients with "treatment-resistant depression and (or) loss of response to Ads actually had bipolar disorder" (Calkin, 438).