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