Understanding psychoses

How can bipolar disorders be understood?

Depressive and manic phases as windows to the soul

Everybody knows about mood swings – between morning and evening, Saturday and Monday, spring and autumn. Depending on events and the passing of time, we distinguish between high spirits and depressiveness. If it were different, the world and life would be incredibly boring. Anyone who feels closely knows already that happy events can exhaust one beyond all measure and unhappy events can drive one towards flight. Furthermore, it is obviously part of our basic configuration as human beings that we doubt about ourselves and at the same time also despair, outthink ourselves and also lose ourselves in the process. In this sense, bipolar disorders are profoundly human independently of a possible genetic disposition. And yet the extent of the swings of mood and drive can be very different.

  • Depression is not the same as grief. Anyone who can grieve and through this also still finds consolation does not need to become depressive. Anyone who becomes depressive is desperately sad. He / she grieves and at the same time tries to escape from the grief. He / she escapes into emptiness and distance from him /herself and thus comes close to desperation. Depressions are full of emptiness, desperation and loneliness. They convey an inability to grieve, at the same time however are also a protective mechanism, a kind of “cataplexy” against subjectively unbearable feelings and irresolvable conflicts.
  • Mania is not the same as happiness. Anyone who is happy, whoever succeeds in life does not need to become manic. Anyone who becomes manic seeks happiness where it is difficult to find, far from his / her own centre and at the same time withdrawn from the supporting relationships. In the process, his / her own effort often goes through all vigours to such an extent that the initial euphoria is soon superimposed by bustling activity and strain. In the avoidance of anxiety and the forsakenness, restlessness becomes ever greater. (Source: “It is normal to be different”, 2007, which can be ordered from info@irremenschlich.de)

Consequence: In depressions and manias people appear (above all to their relatives) to feel strange within their own bodies and still (in retrospect) manage to see through their game: in depressions otherwise suppressed anxieties and unresolved conflicts, in manias unimagined wishes, needs and sometimes also possibilities become visible. It is therefore not only important whether somebody surfaces again or lands after an acute phase, but also how he /she does it.

  • Loss of sense of time: Unlike general mood swings, in the case of bipolar disorders the sense of time can be lost. The depression appears interminable and inescapable, was always so and will always be; correspondingly, the desperation is unending. The mania is experienced as a source of inexhaustible energies; correspondingly, overestimation of one’s capabilities and risk-taking behaviour become boundless. The real vicissitudes of the disease cannot be perceived.

Consequence: Therapy must achieve the almost impossible feat of conveying hope without superficially reassuring the person affected. it must give back a sense of time. As a matter of course, this works better in self-help groups or in special group therapies: in other patients, the phase that you are particularly suppressing just now remains visible. Through the arrangement of the polarity more mobility with a tendency to the centre becomes possible again.

  • Problem of overconformity: Persons with bipolar mood disorder tend to appear overconformed on closer inspection. In their socialization they have learnt to satisfy the expectations of others and accept the standards of others undiscussed. You make every effort to please everybody. Own standards are mostly unconscious and conflict strategies are underdeveloped. The depression makes this dilemma self-evident and can sharpen it even further. The mania appears as an escape attempt in the direction of unconventionality, yet the liberation cannot be really fulfilled and is caught up with by the disorder.

Consequence: Precisely the treatment of bipolar disorders requires a conversion of psychiatry in the direction of comprehensive structural continuity. Not only in the complementary but also in the clinical area, it is important to work in a person-centred way. The same therapist should be responsible – independently of the outpatient or (partly) inpatient treatment status. From a subjective point of view, both phases are in any case closer to each other than one may think.

  • Significance of the feeling of self-worth: People with bipolar disorders have a life story just like other people. Their phases have a start and an end – with or without treatment. Your symptoms have a development history – as well as the resources and coping strategies available. Perhaps the somewhat simplified comparison with bank accounts is helpful: anyone who has money on their savings account can overdraw their current account without running into trouble. Anyone who has used up the reserves no longer has any credit. And anyone who overdraws must pay high interest payments. The feeling of self-worth must be used as currency. It goes without saying, ego-strengthening experiences, love and affection and self-esteem promoting events have a protective effect and opposite are harmful. These effects are not restricted to any phase of life and also not to the time up to the onset of the disorder. They are relevant to the treatment of the disorder, which is why it is already astounding how very little we sometimes manage to avoid personal offences in and through treatment.

Consequence: The primary task of acute and long-term treatment is to avoid new personal offences and help handle old ones, to exercise and incorporate resources and ensure and support individual family / social resources.

  • Interactions: Obviously, there are differences in the way in which we develop or lose feelings of self-worth: Many people are nervous more quickly when their account is overdrawn; others manage to gamble successfully. The emotional battery can empty and fill up more quickly or slowly. The feedback of social perceptions, emotional processing and control of the drive can take place more or less directly. Correspondingly, the range of one’s own emotionality and susceptibility to distinct phases grows. Persons with bipolar disorder not only take personal offence more easily, they also have or develop a highly sensitive perception and react more quickly using their entire energy balance.

Consequence: The treatment must sensitize the person affected for these interactions so that the possibility of self control is strengthened.

  • Is every serious depression potentially bipolar? In the context of bipolar disorders the complaint is often made that the time until the “right” diagnosis took too long. It must be borne in mind however that bipolarity is a follow-up diagnosis, i.e. it may only be made if both phases are sufficiently clearly known. This also means however that virtually every depression can become bipolar, particularly if the flight becomes inescapable. What factors of the personality, surroundings or disorder play a role in the changeover would be fascinating to find out. And yet the absolute distinction of the unipolar and bipolar disorder distorts or overcomplicates this issue.

Important understanding: Precisely the treatment of bipolar disorders requires a conversion of psychiatry in the direction of comprehensive structural continuity. Not only in the complementary but also in the clinical area, it is important to work in a person-centred way. The same therapist should be responsible – independently of the outpatient or (partly) inpatient treatment status. From a subjective point of view, both phases are in any case closer to each other than one may think.

Momentum of bipolar disorders

Depression and mania can be intensified through a momentum more or less typical of the disorder – and namely at a psychic, social and somatic level. A similar understanding, may also apply to psychoses. And yet it is particularly clear here.

  • Typical thought patterns: Depressive thought patterns lead to significant distortions of perception of the one’s own and another person’s accomplishments: disappointments are attributed to one’s own personality, successes to others. Plans lead almost inevitably to failure. The anticipation of defeats feigns sovereignty yet always leads to desperation. In manic phases similar distortions have an effect in the opposite direction.

Consequence: It is important to reverse this mechanism: with perseverance and calmness, the first therapeutic steps must always be challenged until they are so small that success is inevitable. In this regard, the involvement of other persons afflicted in the group setting is helpful.

  • Social interactions: Bipolar disorders affect and put a strain on close relatives to a high degree. This applies to parents and siblings as well as compared with schizophrenic psychoses cumulatively also to partners and children. While the patients are torn between highs and lows in particular the relatives stand in the force field of closeness and distance: How can I protect myself? What distance do I need not to endanger my own love? What closeness can I still tolerate?

Consequence: Relieving the relatives (individually or in groups) also has a therapeutic effect for the patients. Work with bipolar patients without taking into account the relatives (separately or jointly) is a medical malpractice.

  • Somatic momentum: That the cerebral metabolism is involved in extreme mood swings should not be a great surprise to anybody, for this applies to all emotional states and actions. Alone, it can explain them just as little as for example the psychological or social causes. In the meantime, it has even been demonstrated that the changes in the cerebral metabolism are rather the consequence of privations and frustrations, however with the possible tendency to increase the sensitivity to subsequent occurrences. Emotional strains can pave the way for certain neuronal connections and neglect others – possibly with consequences for the future possibilities of processing the symptoms.

Consequence: With the concept of the “biological scars” drug-treatment strategies can also be better substantiated than with the all too simple and false image of direct causality. At the same time, the patient and the therapist remain obliged also to reflect on more complex backgrounds as well as individual and social resources. The drug treatment is complicated enough anyway: antidepressants do not always work and not immediately and increase the risk of a swift (change to mania). Mood-stabilizers and mood-stabilizing antipsychotics do not protect all persons afflicted against relapses and can have side effects. All together therefore are having to grapple with acceptance and cooperation problems. It is all the more important to incorporate and integrate the drug treatment into an overall psychotherapeutic culture.

  • Interactions: The distinction between endogenous, exogenous and reactive states was for good reason abandoned; in a varying degree of emphasis these factors are always represented. Moreover, we know in the meantime very much more about their interactions: psychotherapy also influences many essential physiological variables. Even the genes do not have a deterministic effect, do not determine the person but underlie complex physiological processes, also react to environmental conditions and can be "awoken" in their effectiveness through life crises.

Consequence: The interaction between psychic, social and somatic factors is so complex that monotherapies can hardly still be substantiated.

(Source: T. Bock, Achterbahn der Gefühle, Balance – Buch und Medien Verlag, Germany)

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