I have previously posted current research on the sociocultural factors implicated not only in the course and outcome of the schizophrenias, but also in their initiation and onset. I would now like to present the recent research on these same factors in the bipolar disorders. It is my hope that bipolar illness remains a focus of study, research and therapy for ISPS since psychoanalytic contributions have, within the past decades, been quite scarce. The psychosocial research has been summarized in _Psychosocial predictors of symptoms_ by Sheri Johnson and Bjvrn Meyer in _Psychological Treatment of Bipolar Disorder_ edited by Sheri Johnson and Robert Leahy in 2004 for The Guilford Press. Sadly, psychoanalytic contributions to this volume are missing, reflecting perhaps on our theoretical and psychotherapeutic abandonment of this group of individuals. I had been invited years ago to present at a psychoanalytic conference on bipolar disorder (I believe the first of its kind, especially in New York) in which Kay Redfield Jamison was the keynote speaker.Unfortunatekly, Jamison had to leave prior to my presentation, so I was not able to dialogue with her about her experience, developmental history and her views on the benefits of psychotherapy. In my review paper _The Razor_s Edge: The Struggle to Preserve Self and Object Relations in the Psychoanalytic Therapy of Persons with a Bipolar Disorder,_ I presented the history of psychoanalytic contributions, a neuroscience/neurobiological basis for psychotherapeutic interventions and clinical material illustrating the psychoanalytic theory (Post-Kleinian).

The consensus of the participants was that bipolar is a heavily genetic disorder. The reported concordance rates in MZ twins were inflated. After the conference I did an extensive search of the genetics literature and arrived at a concordance rate of about 50%. This was based on six well controlled studies using strict DSM criteria (see _Genetics of affective disorders_ by Ian Jones, Lindsey Kent and Nick Craddock in _Psychiatric Genetics and Genomics_ edited by Peter McGuffin, Michael Owen and Irving Gottesman in 2002 for Oxford University Press). As I have noted in my analysis of the neurogenetics research in schizophrenia, there are many uncontrolled sources of variance even in studies of MZ twins: effects of prenatal stress (a behavioral teratogen), chorionic blood supply, more similar psychosocial environments than in DZ twins, and nongenomic inheritance of inducible defenses against threat. The effects of environmental sharing in utero is a potential and significant source of variance between MZ & DZ twins. Approximately 65% of MZ twins share a common chorion, while DZ twins never do. A consequence of this shared blood supply could be to increase the chances that environmental factors affects both MZ twins, eg, a viral infection, maternal stress hormones (e.g., cortisol), etc. Competition for nutrition and space could potentially lead to differences in growth rates, neural development, etc. Studies need to be done comparing monochorionic and dichorionic MZ twins to help differentiate this source of error variance. Also, studies need to be done comparing psychological and social factors potentially differentiating MZ from DZ twins in order to arrive at more valid conclusions about genetic factors as a source of variance. Ainslee (1997)has examined in twins such issues as identity confusion, separation and dependency, role complementarity, and concluded that there is a _specific psychology of twinship_ (p. xii)

What is inherited is a vulnerability to, not the certainty of developing the disorder. Certain vulnerabilities appear to be dynamic, not static (reified) conditions. Psychosocial factors are key to gene and illness expression. The genetics reflect incomplete penetrance, Developmental and sociocultural factors must interact with DNA to bring about _dose-response_ phenotypic expressions of the disorders. In recent years the effects of various psychosocial factors on the course of bipolar disorder have been increasingly substantiated.

Predictors of Poor Outcome

Expressed Emotion (EE)

Expressed emotion (EE), defined as emotionally intrusive, critical and hostile comments from various family members towards the person with the disorder, was one of the first variables demonstrated to influence the course of bipolar disorder (Miklowitz, Goldstein et al 1988). The effect size for EE in bipolar disorder was larger than for schizophrenia (Butzlaff & Hooley 1998).The detrimental effects of EE are more pronounced when received from parents than marital partners (Miklowitz et al 2000). Low maternal warmth is a risk factor for relapse in adolescent bipolar patients (Geller et al 2002). Often, there is a proposal that EE is more of a reaction to disturbance than its cause (in the Tienari et al research in schizophrenia, there were no differences in disturbed parental communications between adoptive parents of high vs. low risk subjects-demonstrating that the emergence of a schizophrenia spectrum disorder was not directly causing high EE in the adoptive parents). In bipolar disorder, a series of research studies have suggested that EE holds predictive power even after accounting for subsyndromal symptoms and personality traits (Hooley et al 1995). Family members who may feel unconsciously or consciously responsible for the offspring_s disorder ( e.g., either through _bad_ genes and/or adverse rearing environments), or see symptoms as under the patient_s control, may be more prone to blame the patient and feel angry towards him/her (Hooley 1998).

Social Support

Several studies have suggested that individuals with bipolar disorder experience less social support than those without a mental disorder and that social support is lower for persons with a history of more manic episodes (others may have a fear of contagion- fear of becoming manic or depressed oneself?- reactions to the irritability and hostility of the patient?). An absence of emotional support has been demonstrated to be related to a poorer course of the disorder, including greater number of relapses and poorer response to lithium treatment (Johnson et al 2000).

Negative Life Events

Independent negative life events (exclusive of life events provoked by the disorder itself) are associated with increased risk of relapse (Ellicott et al 1990; Hunt et al 1992) and a slower time to recovery from episodes (Johnson & Miller 1997). Severe life events, e.g., loss of family member or significant friend, seem to be particularly relevant in precipitating symptomatology. Interpersonal events are particularly influential (Hammen et al 1992). Within this domain, the best predictors of illness course are negative life events involving loss (i.e., major separations).

Personality Factors

During episodes, maladaptive personality traits appear elevated (Soloman et al 1996). Prospective research identified sociotropy-i.e., a personality trait involving excessive need for reassurance and sensitivity to interpersonal life events- as a predictor of symptom severity over time in persons with bipolar disorder. Studies have suggested that personality disorders and maladaptive traits contribute to poorer outcomes.

In summary, Johnson and Meyer (2004) noted:

Individuals who are able to maintain noncritical family relationships [I would add the qualifier _relatively,_ I am not aware of any family which is criticality-free], strong social support networks, and lower rates of major life events are likely to experience fewer symptoms of their disorder over time. Beyond the social environment, a better course of disorder may be possible for people with fewer negative interpretations of themselves and their life events, those who are less neurotic, and those who are less dependent on others_ opinions of them [I would qualify this as follows: that the issue of dependency upon the opinions of others really has to do with a disintegration between autonomy and relatedness, e.g., if autonomy is significantly sacrificed in order to maintain an attachment relationship]...Hence, psychotherapeutic interventions may be needed to help individuals develop more supportive social environments, positive self-evaluations [similar to Gaetano Benedetti_s concept of _therapeutic positivization_], and adaptive cognitions regarding stress. Maladaptive personality traits that persist beyond the recovery period may suggest the need for more intensive therapeutic interventions as well_ (p. 87).

Polarity-Specific Findings

Some research evidence has emerged substantiating polarity-specific effects between depression and mania (Johnson & Meyer 2004). Predictors of Depression within Bipolar Disorder Individuals with bipolar disorder and those with unipolar disorder report comparable rates of severe independent life events prior to an episode of depression (Hammen 1995) and family members report negative life events prior to completed suicides in both bipolar and unipolar patients (Isometsa et al 1995). Johnson and Meyer (2004) concluded:

In summary, several preliminary conclusions emerge from the research on psychosocial predictors of depression in persons with bipolar disorder.First, negative life events, low social support, neuroticism, and poor self-esteem appear tied to increases in depression over time. Negative cognitive styles also appear to be correlated with bipolar depression.Although replications are needed, these findings are remarkably parallel with the findings regarding unipolar depression. Drawing on psychosocial as well as neurobiological comparisons of bipolar and unipolar disorder, we have argued that unipolar and bipolar depression are the same in terms of symptom patterns as well as the predictors of course_ (p.95)..

Unique Predictors of Mania

Some theorists have proposed that life events may provoke both depressive and manic episodes through dysregulation of underlying neurobiological systems. Yet, some theorists suggest that the predictors of mania may be somewhat unique, e.g., sleep deprivation and heightened activity in the behavioral activation system.

Sleep Deprivation

Case reports and naturalistic studies (Barbini et al 1996; Leibenluft et al 1996) suggest that manic episodes may follow sleep loss. Frank and Swartz (2004) suggested that life events may operate partially through disrupting sleep patterns and that environmental events and poor social networks may influence bipolar symptoms via the mediating pathway of disrupting circadian rhythms. Bertram Lewin (1950) a Freudian psychiatrist-psychoanalyst, referred to an oral triad which appears in manic patients: the wish to devour, to be devoured and to sleep. There is an intimate conceptual union between the idea of sleeping and dying. Both sleep and death can be expressed as being devoured or can be avoided by exaggerated wakefulness. Mania is then characterized by the denial of the tendency to be devoured, sleep or die (Grinberg, 1992). Guntrip (1962) gave the following description of the function of the manic state in manic-depressive illness: The manic state is not a defense against the repression of active impulses even though that at times enters into it, but a desperate attempt to force the whole psyche out of a state of devitalized passivity and regression. The harder the struggle to defeat the passive regressed ego, the more incapable of relaxation and rest the patient becomes. His mind must be kept going non-stop, night as well as day. Deep sleep is feared as regression and every effort is made either to prevent its occurrence by insomnia [which Guntrip believed to be a manic symptom] or to keep up an constant interference with it y active dreaming, and repeated waking._

Behavioral Activation

Several researchers over the past two decades have proposed that manic symptoms are connected to excessive activity in the behavioral facilitation system/behavioral activation system/behavioral approach system (BAS- Depue & Zald 1993; Fowles 2001). BAS outputs correspond to manic symptoms such as inflated self-esteem, flight of ideas, increased goal-directed activity, and excessive involvement in pleasureable activities. A series of researchers noted that bipolar disorder may reflect dysregulation of the ventral tegmental dopaminergic neurons, which have been hypothesized to be a central tract involved in BAS. Reward responsiveness functions as a symptom-independent stable characteristic in persons with bipolar disorder (Johnson & Meyer 2004). Johnson and Meyer(2004) noted:

In sum, BAS sensitivity, as measured by self-report and psychophysiological indices [e.g., activity in the left anterior cerebral cortex], appears to play an important role in bipolar disorder. Recent research suggests that BAS sensitivity tends to be higher among bipolar than comparison samples, and that relatively higher BAS sensitivity appear to predict greater risk of mania over time_ (p.94).

Life events involving goal attainment (typically, having a new job, new schooling or a new relationship), which are thought to be independent of symptoms, often precede the emergence of manic symptoms (Johnson et al 2000). A series of studies suggests that persons with bipolar disorder and their family members may demonstrate increased goal striving and sensitivity to rewards. Johnson and Meyer (2004) proposed that these _difficulties in goal regulation and reward responsiveness may be expressed in symptoms of mania following life events involving goal attainment_ (p. 96).

Variables That May Predict Both Depression and Mania

Mania might follow both goal-relevant and failure-relevant triggers. The psychoanalytic concept of the _manic defense_ has been applied as a defense against painful depressive affect, feelings of insecurity, etc.Some psychoanalytically oriented clinicians, e.g., Alfred Adler, hypothesized that persons with manic-depression might experience greater emotional responses to failures, and then cope with this through increased goal-pursuit as well defensiveness reflected in inflated self-esteem. Johnson and Meyers (2004) suggested: This hypothesized need for success to ward off failure, whatever its source, may be expressed in greater goal pursuit, which may lead to sleep disruption and excessive involvement in goal pursuit, which in turn may intensify hypomanic symptoms_ (p. 97).

Summary of Psychosocial Risk Variables and the Course of Bipolar Disorder

Johnson and Meyer (2004) concluded:.we have provided an overview of several different predictors of symptom course in people with bipolar disorder. Many variables are associated with increases in symptoms over time, including expressed emotion, negative life events, poor social support, negative cognitive styles, and personality difficulties. Many of these variables seem to exert a stronger influence on depression than mania, and it seems that many of the psychosocial variables that predict unipolar depression may influence the course of bipolar depression. Mania appears specifically influenced by sleep deprivation and increased activity within the behavioral activation system. Although the evidence is not as robust, writers over the past 100 years have suggested that manic symptoms can occasionally reflect a reaction to negative life events and cognitions. Such a reaction could reflect biological instability or a more psychological process-namely, that manic activity may be triggered as a defense against overwhelming feelings of loss or failure...In sum, psychosocial variables appear to play an important role in the exacerbation of symptoms in bipolar disorder, and positive social environments and psychological traits may help reduce the toll of this disorder_ (pp.87-98).

Psychodynamic Speculations Relevant to Bipolar Disorder (Manic-Depression)

Gabbard (1992) in a plea to retain psychic meaning and psychodynamic knowledge in the _Decade of the Brain_ expressed his concerns as follows:_To lose the psychodynamic perspective is to lose the complexity and richness of human functioning in the quicksand of neurotransmitters and molecular genetics. Meaning must be preserved. It is instrumental to the induction of neurobiological changes associated with psychopathology.That which is crucial to etiology and pathogenesis will be also be crucial to informed treatment planning.

Murray Jackson (personal communication) noted: Psychoanalytic concepts offer important contributions to the understanding of psychotic illness, and help to make sense of the apparently meaningless or bizarre thinking and behavior commonly associated with psychotic or delusional states of mind. In this way they can provide a guide for workers with different skills and perspectives and contribute to the formulation of treatment plans appropriate to the patient_s needs, psychological disabilities and assets at any particular time. The integration of a psychoanalytic perspective with other treatment modes is a matter of urgency at the present time when the dazzling achievements of biomedicine and emphasis on brief methods of therapy are bringing the risk that the psychological understanding of the individual will be progressively reflected. At the worst is the prospect that psychiatrists_ skills in psychological understanding and treatment will eventually atrophy.

The latter point has been underscored by Peter Fonagy (1997) in his expressed concerns that our current lack of an _immersion_ experience previously built into our long-term psychotherapeutic work with more seriously disturbed patients will be lost in our current ethos of medication only and infrequent case management visits, thereby resulting in a serious deficit in our knowledge base which we need to have in order to teach future generations of mental health clinicians.

Jackson pointed out that a psychoanalytic perspective can help clinicians decide which type of psychological treatment might be most helpful to a particular patient, and when long term individual psychoanalytic psychotherapy may be indicated. In regard to his own theoretical approach, Jackson noted:

Exploration of the formation and significance of the strange, confusing, and often bizarre elements of thought that are the ingredients of the phenomena of psychosis has been greatly helped by the development of the conceptual tools of object-relation and past object psychology. These concepts sprang from the original works of Freud, Jung and Abraham, which have been developed and expanded in a unique way by Melanie Klein._ On a more directly clinical level, Jackson suggested:

Contact with psychotic patients can be emotionally disturbing, even for experienced professionals, and this is one reason whey psychosis_ treatment is usually best conducted as work within a multi-treater_ team of mental health professionals. Individual psychotherapy with such mentally disturbed patients requires a degree of personal maturity and a special interest, and is therefore, not for everyone. Those who choose it will find that a sufficiently long period of personal psychoanalytically based psychotherapy will help them to understand their less disturbed patients and their own primitive levels of functioning, an experience that can be of great benefit to themselves and their work.

Jackson, based on his extensive clinical experience, expressed a belief that even the most seriously ill patients and those deprived of comprehensive treatment for long periods of time can often benefit from psychotherapy provided that the necessary conditions of an experienced and well-trained psychotherapist and a continuing setting of psychodynamically-informed psychiatric facility is available.

Brian Koehler PhD
New York University
80 East 11th Street #339
New York NY 10003
212.533.5687
brian_koehler@psychoanalysis.net