ArtsAutosBooksBusinessEducationEntertainmentFamilyFashionFoodGamesGenderHealthHolidaysHomeHubPagesPersonal FinancePetsPoliticsReligionSportsTechnologyTravel

What is Bipolar Affective Disorder? - A Factual Review

Updated on July 30, 2019
SanaKateKhan profile image

Sana has a DipHE in Social Care and is completing the final year of BSc(Hon) Socal Care. In 2006 she was diagnosed with bipolar disorder 1

Bipolar affective disorder - A factual review. Written by Sana Kate Khan (2008)

Bipolar affective disorder is a severe brain disorder that causes unusual shifts in mood, energy and activity levels, and hinders the ability to carry out day-to-day tasks. Three elements of this condition include, depressive symptoms, manic symptoms and the cyclic nature of these moods (WHO, 1992). A holistic approach is required to understand and treat the full range of clinical symptoms that contribute to the burden of suffering with this disorder (Joffe, R., 2003). Bipolar disorder is now recognized as a potentially treatable psychiatric illness (Swan, A., 2006). Taking into consideration the most important aspects of biopsychology, pharmacotherapy and psychosocial paradigms, highlighting the contribution psychology can make, this paper will look specifically at a biopsychosocial model of treatment for bipolar disorder. Taking a starting point in biopsychology the paper will discuss the importance of genetic research as a key to understanding bipolar disorder. The work of Craddock and Jones (2001), will raise ethical issues in obtaining these results. The evidence from two structural imaging studies will be compared to test the reliability of biopsychological theories of bipolar disorder. Keeping in a biological framework, psycho-pharmacotherapy will be considered, emphasizing the key mood stabilizers lithium, valproic acid, and carbamazepine as treatment. Using controlled trials a critique will be offered on the efficacy of pharmacotherapy for bipolar disorder. Finally, psychosocial interventions will be discussed, using randomized studies and highlighting the contribution psychology can make in the treatments of bipolar disorder.

The Biological approach.


The National Institute of Mental Health (2000), reports that research is the key to understanding bipolar disorder. Genetics research, data from twin, family and adoption studies demonstrating involvements of genetic factors in the transmission of the disease (Tsuang & Faraone, 1990). This is likely to have an impact on the understanding of bipolar disorders, improving treatments for patients. However, this raises ethical issues (see Craddock & Jones, 2001). Structural imaging of the brain has lead to major a breakthrough in the research of etiology of bipolar disorder. The appearance of abnormalities, in the white matter of the brain in patients with bipolar disorder has been observed (Soares & Mann, 1997). This finding suggests that the white matter abnormalities seen with MRI are related to the presence of the disorder. However a study undertaken by Lopez, et al., 2001, tested for regional prefrontal gray and white matter abnormalities in bipolar disorder patients and the findings were very different. White matter differences were not observed in any of the prefrontal sub regions. In comparison, these results suggest that bipolar patients have sub region-specific gray matter volume reductions in the prefrontal cortex as compared to healthy subjects. To sum, based on the two studies conflicting results, further investigations into the role of specific prefrontal sub regions in bipolar disorder are warranted and necessary.


Lithium is one of the most widely used mood-stabilizing agents for the treatment of bipolar disorder (Yuan, S., et al., 2004). Two other effective drugs for bipolar disorder are valproic acid and carbamazepine (Kalat, 2004). These medications are more effective for patients with bipolar II disorder, which is characterised by depression and milder manic phases. Studies show that lithium appears to be more effective when treating bipolar I disorder, with depression and more severe manic phases (Kleindienst & Greil, 2000). However, studies have shown that when using lithium as monotherapy in treatment of bipolar illness the efficacy is not as great as other medications. One randomised controlled trial compared the efficacy of divalproex, lithium, and placebo as prophylactic therapy and found that patients treated with divalproex had better outcome shan those treated with placebo or lithium on several secondary outcome measures (Bowden et al., 2000). In addition, researchers are currently investigating the efficacy of newer anticonvulsant medications including lamotrigine and gabapentin, as mood stabilizers for treatment refractory bipolar disorder (Post, in progress). Conversely, the atypical antipsychotic medications clozapine and olanzapine that were used originally to treat positive symptoms in schizophrenia, (Williams, L., et al., 2002 and see Duggan, L., et al., 2005) have already been researched and found to have mood stabilizing effects on patients with bipolar disorder (see Suppes, et al., 1999 and also Tohen, et al., 1999). Neuropharmacologists and molecular biologists are making progress in elucidating various second-messenger pathways and gene-regulation pathways altered by various mood stabilizers. An improved understanding in this area will pave the way for a new generation of mood stabilizers for bipolar disorder (Marneras, A. & Angst, J., 2000).

Psychosocial interventions.

An integration of psychotherapeutic techniques with pharmacotherapy has been recommended for the treatment of bipolar disorder (NICE, 2006). Prophylactic agents such as lithium for example, mentioned above, only provide long term benefit for around two thirds of patients (Goodwin, 2002 and see Prien & Potter, 1990). Due to the limitations of the use of pharmacotherapy alone and its efficacy, there has been interest in developing psychosocial treatments specifically designed for bipolar disorder (Lam, 2002). Psychoanalysis, cognitive-behavioural therapy, psycho education, and interpersonal therapy have been used in the treatment of bipolar patients. Psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness (Colom and Lam, 2005).

Psychoanalytical approach – psychoanalysis.

Bipolar disorder attracted the attention of psychoanalysts since the beginning of that treatment (Lam et al., 1999). The most comprehensive review of psychoanalytic thought on bipolar disorder is summarised by Fromm-Reichmann (1949). As with much psychoanalytical thought, the emphasis is placed on mechanisms related to unconscious conflicts that have their origin in early childhood development, the resolution of which will ameliorate present day symptoms (maj, et al. 2002). Rejecting the Freudian school of thought, Willick (1990), argues that there is insufficient evidence to conclude that the aetiology of bipolar disorder, can be attributed to failures in development or fixations during the earliest years of life. Furthermore, he argues that is incorrect to ascribe these failures of development to deficiencies in the early maternal environment. There have been no systematic reviews or controlled trials that have evaluated the psychoanalytical treatment of bipolar disorder (NICE, 2006). This raises thoughts on the efficacy of psychoanalysis.

Cognitive and behavioural approach – CBT.

One study by Lam & Wong (1997) showed that the coping strategies of prodromal symptoms reported by patients of bipolar disorder were behavioural. Cognitive Behavioural theory is a structured psychological intervention derived from the cognitive behavioural model of affective disorders (NICE, 2006). Studies have demonstrated the efficacy of cognitive behavioural interventions in the treatment of bipolar disorder for improving the outcomes for the patient and also in reducing the rate of relapse (Cochran, 1984 and Lam et al., 2000 also Scott, Garland and Moorhead, 2001). Whilst the evidence for cognitive and behavioural interventions for bipolar disorder predicts positive outcomes for relapse prevention, it is not without underlying concern for the efficacy of CBT for patients needing treatment for bipolar depression. Lithium maintenance therapy has been shown to confer a greater reduction in mania compared with depression (2.53- versus 1.8-fold) (Tondo, L. et al., 1998), therefore depression continues to be prevalent even in those bipolar patients who benefit from lithium’s antimanic effects. Despite this, only about one-third of individuals with bipolar depression are in treatment (MDF, 2009). Stahl, (2000) argues than an individual’s cognitions surrounding their depression is understood as a type of moral deficiency, which is shameful and should be hidden. Ultimately, the individual’s cognitions during a depressive episode influence their behaviours, resulting from this up, to 15% of severely depressed patients will commit suicide. One pilot study compares the efficacy of CBT combined with mood-stabilizer pharmacotherapy for bipolar depression; the results showed the preliminary findings suggested that CBT warrants further investigation as an effective psychosocial intervention for depression in bipolar patients (Zaretsky, 1999). Power (2002), argues the classic cognitive therapy framework has too simple a monolithic view of the self-concept; this problem is highlighted in the need for “bidirectional schemas” in the adaptation for bipolar disorders.

Humanistic approach – psychoeducation.

From the humanistic school of thought, pychoeducation- a psychosocial intervention involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs (Schoenstadt, 2006). Studies show psycho education should prove its positive influence on the course and outcome of bipolar disorder (Colom, et al., 1998). On the contrary, highlighting the vulnerabilities of psychoeducation, Simoneau (1999) assessed changes in face-to-face interactional behaviour over 1 year, among families of bipolar patients who received a 9-month family-focused psychoeducational therapy (FFT; n = 22), administered with maintenance pharmacotherapy. No corresponding decreases were seen in negative interactional behaviours.

Psychodynamic approach-Interpersonal and social rhythm therapy.

The approach draws on social-psychodynamic models that reflect the influence of the social psychoanalytic approach of Sullivan (1953) combined with the equal influence social psychiatrist Meyer (1957). Interpersonal and social rhythm therapy (IPSRT) is an interpersonally focused individual psychotherapy that considerers behavioural and environmental interventions. In mania, the subjective experience of time is sped up and in depression it is slowed down, reflecting differences in circadian pathophysiology (Ghaemi, 2006). The Social Rhythm Metric (SRM) (Monk et al., 1991) is completed as part of the assessment. Modulating both biological and psychosocial factors the therapist helps to stabilize the irregularities of sleep-wake cycles, IPSRT is designed to help patients focus on daily routines, be compliant with medications, manage affective symptoms and resolve interpersonal problems that relate to the onset and persistence of an affective episode (Frank, et al., 1999). However further studies are needed to determine whether the approach advocated by IPSRT is the most effective in the treatment of bipolar disorder and therefore requires further consideration. Further what is more, studies are limited. Future research will determine how ISPRT compares to CBT and other evidence based psycho social treatment for bipolar disorder (Frank, 2005).


It is evident that there is a clear need for more systematic clinical management that addresses biological aspects of bipolar disorder. Conflicting evidence from structural imaging studies creates confusion for biopsychology about the aetiology of bipolar disorder. Whilst pharmacotherapy treatment outcomes for lithium are debatable it still remains the ‘gold standard’ prophylactic treatment for bipolar disorder. Progress is being made in elucidating various second messenger pathways and gene regulation pathways. An improved understanding in this area will pave the way for a new generation of mood stabilizers.

There are general limitations to take in to consideration with all the studies based on the psycho social interventions. Most studies have been single-site investigations of single treatments compared with routine care. Based on the evidence there is a need for systematic clinical research on psychotherapy applied to bipolar disorder in order to show its true usefulness. Psychodynamic interventions have limited evidence to prove efficacy of treatment. Meanwhile CBT dominates most clinical practice but has been proven to be effective with only one third of those with bipolar depression in treatment. The frame work of CBT is described having a ‘monolithic view of the self concept’ raising worries about the efficacy in treating bipolar disorders. Psychoeducation is effective but demonstrates vulnerabilities in trials that bring to light the weaknesses in the underpinnings of its philosophy. Finally IPSRT studies prove promising for the treatment of bipolar disorder, but they are limited. Future research will be interesting to follow. Plans to test the strength of the psychodynamics of IPSRT against cognitive behavioural therapies and other evidence based psycho social treatment for will bring new and exciting results for psychology and bipolar disorder treatments.


Bowden, C L., et al., 2000. A randomized, placebo-controlled 12-month trial of divalproex and lithium in treatment of outpatients with bipolar I disorder. Archive of General Psychiatry. 57: 481-489.

Cochran, S. 1984. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. Journal of Consulting and Clinical Psychology. Vol 52(5): 873-878.

Colom, F. & Lam, D., 2005. Psychoeducation: improving outcomes in bipolar disorder European Psychiatry. 20: 369-364.

Colom, F., et al., 1998. What is the role of psychotherapy in the treatment of bipolar disorder. Psychotherapy and psychosomatics.67: 3-9.

Craddock, N. & Jones, I., 2001. Molecular genetics of bipolar disorder. The British Journal of Psychiatry. 178: 128-133.

Duggan, L., et al., 2005. Olanzapine for schizophrenia. Cochrane Database of Systematic Reviews. Issue 2. Art. No.: CD001359. DOI: 10.1002/14651858.CD001359.pub2.

Frank, E., et al., 1999. Adjunctive psychotherapy for bipolar disorder effects of changing treatment modality. Journal of Abnormal Psychology. 108 (4): 579-587.

Frank, E., 2005. Treating bipolar disorder: A clinician’s guide to interpersonal and social rhythm therapy. New York: Guilford Press.

Fromm-Reichmann, F.. 1049. Intensive psychotherapy of manic depressives: a preliminary report. Confinia Neurologica, 9: 158-165.

Ghaemis, S., 2007. Feeling and Time: The Phenomenology of Mood Disorders, Depressive Realism, and Existential Psychotherapy. Schizophrenia Bulletin. 33(1): 122-130.

Goodwin, F.K. 2002. Rationale for long term treatment of bipolar disorder and evidence for long term lithium treatment. Journal of Clinical Psychiatry. 63: 5-12.

Joffe, R., 2003. Treating mood disorders. J Psychiatry Neuroscience. 28 (1): 9-10.

Kalat. J., 2004. Biological Psychology. (8th ed.), Victoria: Wadsworth.

Kleindienst, N,. & Greil, W. (2000). Differential efficacy of lithium and carbamaxepine in the prophylaxis of bipolar disorder: Results of the MAP study. Neuropsychobiology, 42(Suppl. 1), 2-10. (15).

Lam, D. et al., 2000. Cognitive therapy for bipolar illness: A pilot study of relapse prevention. Cognitive Therapy Research. 24 (5): 503-520.

Lam, D. H & Wong, G. (1997). Prodromes, coping strategies, insight and social functioning in bipolar affective disorder. Psychological Medicine, 27, 1091-1100.

Lam, D., et al., 1999. Cognitive therapy for bipolar disorder: a therapists guide to concepts methods and practice. UK: Wiley.

Lam, D.H. 2002. Psychotherapy for bipolar affective disorder. Current Medical Literature. 31: 1-4.

Lopez, M P. Et al., 2002. Regional prefrontal gray and white matter abnormalities in bipolar disorder. Biological Psychiatry, 52(2): 93-100.

Maj, M. Et al. 2002. Bipolar disorder. Wiley: New York.

Marneras, A & Angst, J., 2000. (eds). Bipolar disorders: 100 years after manic depressive insanity. Kluwer Academic Publishers: Great Britain.

MDF - The Bipolar Organisation, 2009. Talking therapies, CBT [online]. Available at: <URL> [Accessed 25 April 2009].

Meyer, H., 1957. Psychobiology: A science of man, Charles Thomas, Springfield.

Monk, H. T., et al., 1991. The Social Rhythm Metric (SRM): Measuring daily social rhythms over 12 weeks, Psychiatry Research. 36: 195–207.

National Institute of Mental Health, 2000. Bipolar disorder research at the National Institute of Mental Health [online]. USA: NIMH. Available at: <URL>

[Accessed 01 May 2009].

NICE, 2006. Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary care. Great Britain: Alden Press.

Post, R M., in progress. New treatment for refractory affective illness. NIMH Grant Number: 1Z01MH02755-02.

Power. M. J., 2002. Integrative therapy from a cognitive-behavioural perspective. In: J. Holmes and A. Bateman, Editors, Integration in psychotherapy: Models and methods, Oxford University Press, Oxford.

Prien, R.F. & Potter, W.Z. 1990. NIMH workshop report on treatment of bipolar disorder. Psychopharmacology Bulletin, 26: 409-427.

Schoenstadt, A., 2006. Bipolar Psychosocial Treatments: Psychosocial Treatments for Bipolar Disorder [online]. US: eMedTV. Available at <URL> [Accessed 02 April 2009].

Scott, J., 1995. Psychotherapy for bipolar disorder The British Journal of Psychiatry 167: 581-588.

Scott, J., et al., 2001. A pilot study of cognitive therapy in bipolar disorder, Psychological Medicine 31: 459–467.

Scott, J. 2005. Encyclopaedia of cognitive behaviour therapy. Springer: United States.

Simoneau, T., 1999. Bipolar disorder and family communication: Effects of a psychoeducational treatment program. Journal of Abnormal Psychology. 108(4): 588-597.

Soares, J C & Mann, J J., 1997 The anatomy of mood disorders – review of structural neuroimaging studies. Biological Psychiatry, 41: 86-106.

Stahl, S., 2000. Essential Psychopharmacology of depression in bipolar disorder. Cambridge University Press: Cambridge.

Sullivan, H. S., 1953. The interpersonal theory of psychiatry, Norton: New York.

Suppes, T., et al,. 1999. Clinical outcome in a randomized 1-year trial of clozapine verses treatment as usual for patients with treatment resistant illness and a history of mania. American Journal of Psychiatry, 156(8): 1164-1169.

Swann, A., 2006. What is bipolar disorder? Am J Psychiatry. 163: 177-179.

Tohen, M., et al., 1999. Olanzapine versus placebo in the treatment of acute mania. Olanzapine HGEH Study Group. American Journal of Psychiatry, 156(5): 702-709.]

Tondo, L.,et al., 1998. Lithium maintenance treatment of depression and mania in bipolar I and bipolar II disorders. Am J Psychiatry. 155: 638–45.

Tsuang, M T & Faraone, S V, 1990. The genetics of mood disorders. Baltimore, MD: John Hopkins University Press.

Williams, L., et al., 2002. Colzapine-resistant schizophrenia: a positive approach. The British Journal of psychiatry. 181: 184-187.

Willick, M.S., 1990. Psychoanalytic Concepts of the etiology of Severe Mental illness. Journal of American. Psychoanalytical Association. 38: 1049-1081.

World Health Organisation, 1992. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organisation, Geneva.

Yuan S., 2004. Lithium, a Common Drug for Bipolar Disorder Treatment, Regulates Amyloid-β Precursor Protein Processin. Biochemistry. 43 (22): 6899–6908.

Zaretsky, A. et al., 1999. Cognitive Therapy for Bipolar Depression: A Pilot Study. Can J Psychiatry. 44: 491–494.

© 2019 Sana Kate Khan


    0 of 8192 characters used
    Post Comment

    No comments yet.


    This website uses cookies

    As a user in the EEA, your approval is needed on a few things. To provide a better website experience, uses cookies (and other similar technologies) and may collect, process, and share personal data. Please choose which areas of our service you consent to our doing so.

    For more information on managing or withdrawing consents and how we handle data, visit our Privacy Policy at:

    Show Details
    HubPages Device IDThis is used to identify particular browsers or devices when the access the service, and is used for security reasons.
    LoginThis is necessary to sign in to the HubPages Service.
    Google RecaptchaThis is used to prevent bots and spam. (Privacy Policy)
    AkismetThis is used to detect comment spam. (Privacy Policy)
    HubPages Google AnalyticsThis is used to provide data on traffic to our website, all personally identifyable data is anonymized. (Privacy Policy)
    HubPages Traffic PixelThis is used to collect data on traffic to articles and other pages on our site. Unless you are signed in to a HubPages account, all personally identifiable information is anonymized.
    Amazon Web ServicesThis is a cloud services platform that we used to host our service. (Privacy Policy)
    CloudflareThis is a cloud CDN service that we use to efficiently deliver files required for our service to operate such as javascript, cascading style sheets, images, and videos. (Privacy Policy)
    Google Hosted LibrariesJavascript software libraries such as jQuery are loaded at endpoints on the or domains, for performance and efficiency reasons. (Privacy Policy)
    Google Custom SearchThis is feature allows you to search the site. (Privacy Policy)
    Google MapsSome articles have Google Maps embedded in them. (Privacy Policy)
    Google ChartsThis is used to display charts and graphs on articles and the author center. (Privacy Policy)
    Google AdSense Host APIThis service allows you to sign up for or associate a Google AdSense account with HubPages, so that you can earn money from ads on your articles. No data is shared unless you engage with this feature. (Privacy Policy)
    Google YouTubeSome articles have YouTube videos embedded in them. (Privacy Policy)
    VimeoSome articles have Vimeo videos embedded in them. (Privacy Policy)
    PaypalThis is used for a registered author who enrolls in the HubPages Earnings program and requests to be paid via PayPal. No data is shared with Paypal unless you engage with this feature. (Privacy Policy)
    Facebook LoginYou can use this to streamline signing up for, or signing in to your Hubpages account. No data is shared with Facebook unless you engage with this feature. (Privacy Policy)
    MavenThis supports the Maven widget and search functionality. (Privacy Policy)
    Google AdSenseThis is an ad network. (Privacy Policy)
    Google DoubleClickGoogle provides ad serving technology and runs an ad network. (Privacy Policy)
    Index ExchangeThis is an ad network. (Privacy Policy)
    SovrnThis is an ad network. (Privacy Policy)
    Facebook AdsThis is an ad network. (Privacy Policy)
    Amazon Unified Ad MarketplaceThis is an ad network. (Privacy Policy)
    AppNexusThis is an ad network. (Privacy Policy)
    OpenxThis is an ad network. (Privacy Policy)
    Rubicon ProjectThis is an ad network. (Privacy Policy)
    TripleLiftThis is an ad network. (Privacy Policy)
    Say MediaWe partner with Say Media to deliver ad campaigns on our sites. (Privacy Policy)
    Remarketing PixelsWe may use remarketing pixels from advertising networks such as Google AdWords, Bing Ads, and Facebook in order to advertise the HubPages Service to people that have visited our sites.
    Conversion Tracking PixelsWe may use conversion tracking pixels from advertising networks such as Google AdWords, Bing Ads, and Facebook in order to identify when an advertisement has successfully resulted in the desired action, such as signing up for the HubPages Service or publishing an article on the HubPages Service.
    Author Google AnalyticsThis is used to provide traffic data and reports to the authors of articles on the HubPages Service. (Privacy Policy)
    ComscoreComScore is a media measurement and analytics company providing marketing data and analytics to enterprises, media and advertising agencies, and publishers. Non-consent will result in ComScore only processing obfuscated personal data. (Privacy Policy)
    Amazon Tracking PixelSome articles display amazon products as part of the Amazon Affiliate program, this pixel provides traffic statistics for those products (Privacy Policy)
    ClickscoThis is a data management platform studying reader behavior (Privacy Policy)