Elsevier

Clinical Psychology Review

Volume 21, Issue 8, November 2001, Pages 1193-1209
Clinical Psychology Review

CIRCADIAN RHYTHMS, MULTILEVEL MODELS OF EMOTION AND BIPOLAR DISORDER—AN INITIAL STEP TOWARDS INTEGRATION?

https://doi.org/10.1016/S0272-7358(01)00111-8Get rights and content

Abstract

This paper sets out possible links between disruption of circadian rhythms in bipolar disorder and the affective symptom, which are experienced in this disorder. Evidence is drawn from Healy and Williams' [Psychiatr. Dev. 1 (1989) 49.] review of circadian function in manic depression, along with later reports, which indicate a role for disrupted circadian rhythms in both depressed and manic phases of manic depression (bipolar disorder). This is integrated within a version of the multilevel model of emotion proposed by Power and Dalgleish [Cognition and emotion: from order to disorder. Hove: Psychology Press (1997); Behav. Cognit. Psychother. 27 (1999) 129.]. The aim of this process is to propose a possible psychological mechanism by which the disruption of circadian rhythms might result in the observed clinical symptoms of bipolar disorder. The integration of these approaches leads to a number of specific testable hypotheses that are relevant to future research into the psychological treatment and understanding of bipolar disorder.

Section snippets

INTRODUCTION

Bipolar disorder is relatively common, affecting around 1–1.5% of the population Bettington & Ramana, 1995, Weissman et al., 1988). Kraepelin (1921) distinguished manic depressive psychosis from dementia praecox primarily by the more benign course of the former. However, evidence in relation to people diagnosed as manic depressive is that it is an illness characterised by repeated episodes Tohen et al., 1990, Zis et al., 1980, increasing frequency of relapse (Goodwin & Jamison, 1990), and high

CIRCADIAN RHYTHMS IN BIPOLAR DISORDER

Bipolar disorder is generally seen as being caused by a complex interaction between biochemical, psychological, physiological, and genetic factors. Although, as Scott (1995) has noted, there has been a historical emphasis on the genetic/biological aspects of bipolar disorder, there is also evidence that psychosocial stressors are associated with risk of onset of manic and depressed episodes (e.g. Bebbington et al., 1993, Ramana & Bebbington, 1995). Recently, there has been much work undertaken

PSYCHOLOGICAL TREATMENT APPROACHES IN BIPOLAR DISORDER

Prien and Potter (1990) have stated that the current situation with regard to psychological interventions in bipolar disorder is analogous to that for therapy of schizophrenia and related disorders around 10 years ago. Although this comment was a decade ago, the 10-year gap between the two seems to still exist. There are very few published studies at present, although there are a number of multicentre trials in progress employing cognitive behavioural approaches.

The first pilot study of

MULTILEVEL APPROACH TO COGNITION AND EMOTION

Much clinical practice is based on single-level approaches to emotion. Thus, Beck's approach identifies a direct link between cognition and emotion across a range of psychiatric conditions (e.g. Beck et al., 1990, Beck et al., 1979). Although his approach to cognitive therapy has had clear benefits in the development of effective psychological treatment as indicated by recent metanalyses of CBT treatment trials (e.g. Gloaguen, Cottraux, Cucherat, & Blackburn, 1998), there are problems with the

Mania

Power and Dalgleish (1997) characterise mania as a disorder of happiness although they acknowledge the problems inherent in this characterisation given that mania is commonly coexistent with depression or at least sequentially related to it in the process of bipolar disorder. However, a circadian approach would suggest that mania, like depression, is associated in the first instance with dysphoria. The secondary effect of elation (disordered happiness) could then be a consequence of appraisal

Prodromes and Prodromal Behaviour

Lam et al. (2000) and Lam and Wong (1997) have reported on the identification and use of prodromes in people with bipolar disorder. People with this diagnosis who could identify and act to moderate the effects of prodromes were at reduced risk of relapse. Whilst significant disruptions of circadian function have been associated with relapse, clearly, people with a diagnosis of bipolar disorder will, just as with anyone else, be coping with more minor circadian fluctuations on a regular basis

CONCLUSION

It has been argued that substantial evidence exists to indicate that disruptions to circadian functioning can be associated with either manic or depressive relapses of bipolar disorder. By adopting the approach of Power and Dalgleish, a model is proposed in which the interpretation of such circadian changes leads to both the initial symptoms of either state and then to forms of behaviour, which would tend to exacerbate the state triggered. It is suggested that cognitive therapy approaches

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