Bipolar 2 Disorder (BD) is just one type of Bipolar disorder. This is a mental illness which at its core is made up of re-occurring events of mood swings through cycles of mania and depression. Theoretically it is possible that at its center, the disorder is comprised of mood instability and emotion dysregulation (Stegmayer et al., 2015).
Some neurobiology studies many of which were performed using functional magnetic resonance imaging (fMRI) have shown that in certain areas of the brain, there are differences between persons without the disorder and those that have bipolar 2 disorder. These studies have shown that these differences are primarily in the areas of the brain such as the amygdala that have to do with the processing of emotions. In other areas there have been regular findings that in both persons who are currently displaying symptoms or who are not displaying symptoms, there are areas of the brain that process emotions which show hyperactivity. There are also studies that consistently provide information from neuropsychology that enumerate deficits in brain processes that control both attention and working memory (Stegmayer et al., 2015).
Bipolar 2 Disorder
One area in the realm of theory that, although can use improvement and has become much more accurate especially with bipolar 2 disorder, is in the Diagnostic and Statistical Manual of Mental Disorder’s fifth edition (DSM5). The DSM5 gives the diagnostician the ability to add specifiers to the basic five of nine necessary symptoms. This allows the addition of mixed features and further reduces the number of not otherwise specified Bipolar 2 Disorder sufferers. It also reduces the amount of exclusions in the diagnosis thus increasing the subthreshold criterion to a clinically diagnosable level (Angst, 2013).
An item of importance that currently moves some people out of diagnosis and others in with Bipolar 2 Disorder, is the specific type of mood changes that are seen. The mood changes must now be seen in the context that they be accompanied by an increase in activity or energy (Angst, 2013). Although more restrictive, they show that the theory behind the diagnosis of bipolar disorder is changing and in those changes we can see that diagnostics is becoming more accurate.
Another area that posits some of the newest theory about Bipolar Disorders both bipolar 2 disorder and bipolar 1 disorder comes from the biological perspective. Accepting that bipolar is a pathological mood disturbance, studies in genetic epidemiology that look at family history have shown that there is a link from this to Bipolar Disorders . It is also likely that family history helps in prediction of a course of the disorder in persons who present with depression (Craddock & Sklar, 2013). This article goes on to further show that the biological theories that utilize studies of genetic variation are strong and replicable. These types of studies are important in that chromosome variation can help the school of psychiatric genetics to view contributions of genetic variation as a factor in vulnerability (Craddock & Sklar, 2013) .
Assessment
As for assessment, I have encountered, while doing research, what appears to be an attempt to link a medical model of looking at disease, which is called staging, with the type of categorical psychological assessment that is currently in place. This current type of assessment can often fall short as noted in (Frank, Nimgaonkar, Phillips, & Kupfer, 2015). It is not conducive to understanding the etymology, development or comorbidities that can occur in bipolar 2 disorder. In this case (Frank, Nimgaonkar, Phillips, & Kupfer, 2015) propose a way of looking at Bipolar Disorders through stages. This type of staging will use genetic and neuroscientific information in combination with actions and mood to look at the progression of the disease.
This type of evaluation looks at the person as a whole from an early stage of the problem where there may be risk but no symptoms to end stage severity where the illness is chronic. In each time period or progression the disorders, both Bipolar 2 disorder and Bipolar 1 disorder are related with imaging, genetics and other biological information which takes into account other physical problems associated with the mental disorder. The idea behind it is that this type of assessment will be used to create targeted therapies for disorders like Bipolar 2 Disorder that will be used in a more individual manner (Frank, Nimgaonkar, Phillips, & Kupfer, 2015).
In (Kapczinski et al., 2014) it states that the assessment of Bipolar Disorders with staging had been first proposed in about 1993. The staging is described as a mental shortcut that can be used to show where a person who might be suffering Bipolar 2 Disorder lies on a scale from at risk to end stage. It would be an easier way for the doctor giving the prognosis to come up with treatment methods that are targeted at the particular advancement of the disease. It further demonstrates that by using additional information beyond the categories such as those in the DSM 5, there is proof that persons who have Bipolar Disorders have deficits in cognitive functioning and that this impairment is an indication of poor psychological and social functioning as well as a worsening clinical course.
Differentiate
This is also a way to differentiate early and late stages of bipolar disorders in that in the early stages of the disorder there has been identified memory, attention and executive functioning problems but in later stages there is also a greater amount of relevant comorbid medical conditions. Through this identification, certain targeted medications have been shown to produce a positive response in these same later stage disorders which suggests that when the stages are identified, responses can be tailored (Kapczinski et al., 2014).
Staging looks at different structures and functions during the different progressions of the disease. There are corresponding losses of gray matter in later stages of Bipolar Disorders . There are studies of orbitofrontal cortex volume loss in later stage illness that is similar to these earlier studies. Some neuroimaging has shown changes in the prefrontal cortex among other cortices as well as the fusiform gyrus. Although in many cases the latter stage disease coincides with worse treatment outcomes and negative prognosis, it is a good argument for assessment through stages to combat the illness in its earliest forms (Kapczinski et al., 2014).
Treatment
The treatment of Bipolar Disorders is a complex situation which is often difficult. In many cases the use of psychopharmacology is paired with psychotherapy for Bipolar 2 Disorder. As pointed out in (Geddes & Miklowitz, 2013) both of these types of treatment have questionable results. The goal is typically to bring a patient who is in either mania or depression to a stable mood state with the prevention of relapse and a lessening of symptoms. Because of the nature of Bipolar Disorders which has proven to be distinct from unipolar depression, treatment that deals with both sides of the disorder can be difficult because the same treatments that alleviate depression can move a person toward mania.
When treating mania there is a chance that the client can become depressed (Geddes & Miklowitz, 2013). This goes on to show that one of the main reasons that we have not come across better treatments is that our knowledge of the mechanisms that cause the disease is limited. This is supported by the fact that there is a paucity of information that shows the effects of the medications on the target areas as evidenced by less than stellar animal and human experimental drug models (Geddes & Miklowitz, 2013).
In addition to pharmacological responses there is also psychotherapy. One study of group therapy in (Geddes & Miklowitz, 2013) showed that by using psychoeducation to bring about the clients awareness of the disease, the importance of treatment follow through and stressing the importance of regular sleeping habits, there were fewer relapses and less illness than in groups that had not received the treatment. This reduced the hospital stay lengths and reduced the cost of treatment significantly.
Other Issues
From (Palermo et al., 2016) one can see that there is suggestive research that shows that insomnia contributes to symptoms that could result in more problems with mental health conditions such as bipolar 2 disorder. In this case it shows that there can be recurrence of symptoms. It also goes on to say that there is evidence for the use of CBT to treat adjunct disorders such as insomnia and that it has proven to be effective in the treatment of Bipolar Disorders .
The article showed that changes in the sleep and wake cycles can lead to physical and mental health changes. It provided evidence that results for treatment of insomnia and other sleep problems helped to improve symptoms of adults with Bipolar Disorders . Treatment with CBT becomes more efficacious with better sleep habits. In some cases if the direct treatment of bipolar symptoms is not effective there are other means by which therapies can be used effectively to help with BD symptoms.
Can it affect my work?
These finding are significant to my current work. I am now being tapped to do work with co-occurring populations that are releasing from jail. These men and women are those that need the most help of all. They have substance use issues and are often times diagnosed with other mental health issues. The prevalence rates of Bipolar Disorders are high.
By seeing that even though it is difficult to treat there are still ways in which therapeutic treatment can be effectively administered is a great help to me in my work with clients. I can now see that if I am unable to use some of the techniques to directly treat the main symptoms of bipolar then I could still use therapy to help areas that might assist in the relief of symptoms. It is somewhat like when someone told me that if I strengthened my stomach it would help my back. I could not fix the pain in my back by exercising it but I could do so by doing another exercise that worked another part of my body. In this way I was able to treat my problems.
More importantly for me is the fact that this type of studying will help me to make referrals. In many cases I have to deal with and coordinate therapy sessions and doctors’ appointments. If I notice that bipolar 2 disorder or any version of BD symptoms are prevalent I can at least attempt to give this information to the person or persons who will be helping to diagnose a person who could possibly have a mental illness. Although I will not be making the diagnosis, I believe that a diagnosing physician could benefit from having more information about the client especially information that comes from a highly educated and trained source with this type of knowledge.
An example that I have from my life in regards to treatment of Bipolar Disorders is with a female family member. This person suffers from Bipolar Disorders and also suffers from psychosis in the form of delusional thinking. This does not happen all the time. During the phases of mania this person is more apt to not sleep which can cause more problems.
In one of the most recent types of treatment she has been attending a group therapy session using dialectic behavior therapy. She likened the therapy to that of a twelve step group. The work she was doing didn’t seem to make sense to her in that it really had nothing to do with what was going on in her head. She did tell me that although it seemed to have nothing to do with the disorder it was helping her. I believe that this is in line with the earlier hypothesis and certain studies that therapies that do not necessarily address the disorder directly but work on some of the barriers that cause further degradation of mental states in persons with Bipolar Disorders can be effective in helping with fewer relapses and less hospitalization (Palermo et al., 2016).
Cultures Effects
Culture is an interesting aspect of any disorder. In many cases culture can help to define treatments and even in some case diagnoses of bipolar 2 disorder. Cultural is particularly important in that is a highly individual area. The diagnosed person defines and determines their own culture. In most cases it is vital to speak with the person to understand their culture. Culture effects so much of the diagnosis and treatment of mental disorders and this includes areas of questionnaires to determine mental health, consultation and ties in with biological genetic variants in the prevalence of the disorder. Culture can encompass, ethnicity gender and many other forms (Power, Kyaga, & Uher, 2013; Flynn, Berkout, & Bordieri, 2016; Interian, Lewis-Fernández, & Dixon, 2013; Bedoya et al., 2014).
The importance of culture on questionnaire and testing methods can be seen in a study from (Flynn, Berkout, & Bordieri, 2016). The idea behind cultural considerations when using testing methods comes from the attempt to show that therapeutic methods such as acceptance and commitment therapy (ACT) has the ability to treat pathological behavior’s and problems that can occur in persons suffering from mental illness but that is does so across cultures. It appears preferable that the methods and testing that one uses are scientifically validated for uses across cultures.
Other Studies
(Flynn, Berkout, & Bordieri, 2016) uses samples of college students and the low rates of persons with mental illness who present with problems and seek treatment as a prime example for the need to offer culturally competent services and outreach to improve the number of persons who seek treatment. The study noted that the newest questionnaires that measured for significance rates in the positive outcomes of treatment for psychological inflexibility had been recently manipulated to take into consideration cultural issues. This in turn allowed for better examination of this particular treatment modality in the treatment of cultural specific populations
It is apparent through studies that when cultural alterations are designed into treatment interventions and delivery systems it improves their effectiveness (Flynn, Berkout, & Bordieri, 2016).This study primarily concerns itself with Hispanic populations but was done with the mindset that initial trials had only dealt with white and other than white populations. It is still an example of cultural specific changes within the context of culturally delivered services in dealing with population that are culturally diverse. Cultural differences do in fact limit the generalization of treatment and there are still ways to change and measure those same treatments through the lens of cultural diversity The end result of the study not only adds to the literature on the importance of cultural consideration in treatment but it also points a direction that anyone can take into increased awareness of the use of culture in treatment.
A main reason behind cultural focus is because in many cases there are inequities in mental health treatment when it pertains to underserved ethnic and racial populations according to (Interian, Lewis-Fernández, & Dixon, 2013). They posit that this divide is due to the limits imposed by an inability to engage diverse populations. Reasons for the divide also include issues such as access to care and lower treatment quality. This would be particularly devastating in populations that suffer from Bipolar Disorders that are already compromised when it comes to diagnosis in that the time involved in misdiagnosis can be extremely long (Phillips & Kupfer, 2013). Less access can only increase this wait time. The (Interian, Lewis-Fernández, & Dixon, 2013 ) study looks at the advances in engagement and the effectiveness of interventions. It suggests that the evidence for their use in underserved populations be reviewed. In this way the best treatment approaches can be implemented that point to better outcomes from a cultural standpoint.
Legal Issues in Treatment
Oftentimes there are legal issues in treatment. This is a consideration in any therapeutic setting especially when dealing with Bipolar 2 Disorder . In the (Appelbaum, 2007) study, the writers looked at the issues of informed consent. The context of a patient’s inability or lack of competence to provide consent was the focus. In many cases there is an ethical and oftentimes legal mandate to obtain informed consent. The study notes that for informed consent to be valid, there must be appropriate disclosure and it must be to a competent patient who has the capacity to make choices of their own will. The use of a third party is necessary if the courts find a person incompetent. The design of informed consent is to allow autonomous decisions to those persons with the ability but also to protect those who are not able to give consent.
From the study (Lee et al., 2013) we can infer that persons with Bipolar Disorders have social and community function deficits especially when they are in a mood episode. In this case it would be important to evaluate carefully the person who is diagnosed with bipolar and in a manic or depressed state in the case of informed consent.
Another facet of legal interest is that many sufferers of bipolar disorder can have violent episodes. The study (Volovka, 2013) considers some issues with violent behavior. The type of violence that comes about as a result of both manic and depressive features of Bipolar Disorders sufferers was seen as a contributor to negative stigma and as a complicated challenge to manage from a clinical aspect. Violence is expensive, increases hospital stays and can be a dangerous to the general public. The cost to the criminal justice system is also more expensive.
Violence
It is critical to manage the violence that can occur as a result of patients who suffer mental illness such as Bipolar 2 Disorder. A study recommends using both pharmacological and therapeutic interventions such as cognitive behavioral therapy in conjunction to assist in this task (Volovka, 2013). The legal ramifications that can result from the non-treatment of persons who exhibit violent systems should be of great concern. There is also an ethical obligation. It is important to care for a person who is mentally ill and can possibly harm themselves or others, so that there is no harm. This is especially true in the case of suicidal ideation.
In many cases there is a link between aggression and suicide. This is true in cases of Bipolar 2 Disorder as well as Bipolar 1 disorder (Volovka, 2013). When we look at patients with Bipolar Disorders for their level of violence in conjunction with suicidality, there is a positive correlation between aggression and suicide attempts. This study makes note of other information wherein persons suffering Bipolar Disorders show much greater impulsivity, aggression and suicidal ideation than persons who did not suffer Bipolar Disorders . It seems apparent that any treatment of persons with Bipolar Disorders should also take into account the higher rates of suicide of Bipolar Disorders sufferers when it comes to possible legal issues.
References
Bipolar 2 Disorder
Angst, J. (2013). Bipolar disorders in DSM-5: strengths,problems and perspectives. International Journal of Bipolar Disorders, 1(12), 1-3. doi:10.1186/2194-7511-1-12 201607062004501338423610
Appelbaum P S 2007Appelbaum, P. S. (2007). New England Journal of Medecine, 357, 1834-1940. doi:10.1056/NEJMcp074045 201607101235591488386989
Bedoya, C. A., Treager, L., Trinh, N. T., Chang, T. E., Brill, C. D., Hails, K.,…Yeung, A. (2014). Impact of a Culturally Focused Psychiatric Consultation on Depressive Symptoms Among Latinos in Primary Care. Psychiatric Services, 65(10), 1256-1262. Retrieved from http://dx.doi.org/10.1176/appi.ps.201300088
Benazzi F. Bipolar disorder — focus on bipolar 2 disorder and mixed depression. Lancet . 2007 Mar 17;369(9565):935-45
Craddock, N., & Sklar, P. (2013). Genetics of bipolar disorder. The Lancet, 381(9878), 1654-1662. doi:http://doi.org/10.1016/S0140-6736(13)60855-7
Flynn, M. K., Berkout, O. V., & Bordieri, M. J. (2016). Cultural considerations in the measurement of psychological flexibility: Initial validation of the Acceptance and Action Questionnaire–II among Hispanic individuals. Behavior Analysis: Research and Practice, 16(2), 81-93. doi:10.1037/bar0000035
Frank, E., Nimgaonkar, V. L., Phillips, M. L., & Kupfer, D. J. (2015). All the world’s a (clinical) stage: rethinking bipolar disorder from a longitudinal perspective. Molecular Psychiatry, 20(1), 23-31. doi:10.1038/mp.2014.71
Gaudiano, B. A., Nowlan, K., Brown, L. A., Epstein-Lubow, G., & Miller, I. W. (2013). An Open Trial of a New Acceptance-Based Behavioral Treatment for Major Depression with Psychotic Features. Behavior Modification, 37(3), 324-355. doi:10.1177/0145445512465173
Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, (9878), 1672-1682. doi:http://doi.org/10.1016/S0140-6736(13)60857-0
Interian, A., Lewis-Fernández, R., & Dixon, L. B. (2013 ). Improving Treatment Engagement of Underserved U.S. Racial-Ethnic Groups: A Review of Recent Interventions. Psychiatric Services, 64(3), 212-222. doi:10.1176/appi.ps.201100136
Kapczinski, F., Magalhães, P. S., Balanzá-Martinez, V., Dias, V. V., Frangou, S., & Gama, C. S.,…Vazquez, G. (2014). Staging systems in bipolar disorder: an International Society for Bipolar Disorders Task Force Report. Acta Psychiatrica Scandinavica, 130(5), 354-363. doi: 10.1111/acps.12305
Lee, J., Altshuler, L., Glahn, D. C., Miklowitz, D. J., Oschner, K., & Green, M. F. (2013). Social and Nonsocial Cognition in Bipolar Disorder and Schizophrenia: Relative Levels of Impairment. American Journal of Psychiatry, 170(3), 334-341. Retrieved from http://dx.doi.org/10.1176/appi.ajp.2012.12040490
Palermo, T. M., Bromberg, M. H., Beals-Erickson, S., Law, E. F., Durkin, L., Noel, M., & Chen, M. (2016). Development and initial feasibility testing of brief cognitive-behavioral therapy for insomnia in adolescents with comorbid conditions. Clinical Practice in Pediatric Psychology, 4(2), 214-226. doi:10.1037/cpp0000140
Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder diagnosis: challenges and future directions. The Lancet, 381(9878), 1663-1671. doi:http://doi.org/10.1016/S0140-6736(13)60989-7
Power, R. A., Kyaga, S., & Uher, R. (2013). Fecundity of Patients With Schizophrenia, Autism, Bipolar Disorder, Depression, Anorexia Nervosa, or Substance Abuse vs Their Unaffected Siblings. JAMA Psychiatry, 70(1), 22-30. doi:10.1001/jamapsychiatry.2013.268.
Stegmayer, K., Usher, J., Trost, S., Henseler, I., Tost, H., & Rietschel, M.,…Gruber, O. (2015). Disturbed cortico-amygdalar functional connectivity as pathophysiological correlate of working memory deficits in bipolar affective disorder. European Archives of Psychiatry & Clinical Neuroscience, 265(4), 303-311. doi:10.1007/s00406-014-0517-5
Volovka, J. (2013). VIOLENCE IN SCHIZOPHRENIA AND BIPOLAR DISORDER. Psychiatria Danubina, 25(1), 24-33. Retrieved from http://www.antoniocasella.eu/archipsy/Volavka_2012.pdf
White, R., Gumley, A., McTaggart, J., Rattrie, L., McConville, D., Cleare, S., & Mitchell, G. (2011). A feasibility study of Acceptance and Commitment Therapy for emotional dysfunction following psychosis. Behaviour Research and Therapy, 49(12), 901-907. doi:10.1016/j.brat.2011.09.003