Monday, February 12, 2007

Depression and Mania: The Bipolar thinking style

PsyBlog has recently posted an article on Cognitive Therapy (CBT) and how it is useful in Depression treatment. this therapy has been shown to be equally effective in Depression as is medication, though this woks in a top-down fashion in the brain (revealed by brain scans), while anti-depressants work in a bottom-up fashion.

PsyBlog quotes the following irrational beliefs , as outlined by Beck, that are prominent in Depression.

* Over-generalization. Drawing general conclusions from a single (usually negative) event. E.g. thinking that failing to be promoted at work means a promotion will never come.
* Minimalization and Maximization. Getting things out of perspective: e.g. either grossly underestimating own performance or overestimating the importance of a negative event.
* Dichotomous thinking - Thinking that everything is either very good or very bad so that there are no gray areas. In reality, of course, life is one big gray area.

To me all of these beliefs are equally relevant for Manic thinking, although in the Manic case these beliefs would be about positive events and have a different spin.

  • Over-generalization: a single instance of success at some endeavor disposing one to think that one can achieve anything in unrelated fileds. Also more co-incidence detection and more correlation-is-causation type of thinking that may ultimately lead to the Magical Thinking of full-blown Psychosis.
  • Minimalizations and Maximizations: Here, again, things go out of perspective: Overestimating one's own performance and underestimating the importance of external happenstances that might have led to success.
  • Dichotomous thinking: thinking that things are mostly good/bad and unfounded optimism/faith/trust - the opposite of the depressive feeling. Although the reverse thinking that things are mostly bad (external environment is bad, I am good) can also kick in. The point is seeing the world in Black/white but not in shades of gray.

PsyBlog also has an earlier post on depressive thinking style in which it elaborates on the internal-locus-of-control predisposition in depressive probands. Thus, the depressive style is marked by the following internal, global and stable attributions: :

* It is my fault that I didn't get the job. Here I have made an internal attribution.

* I think I am worthless: a thought that is likely to affect all areas of my life. Now I am making this attribution global.

* I see no reason for the fact that I am worthless to ever change. Now the attribution is stable

It is clear that the Manic person too makes the similar attributions: His success (maybe a single, lucky success) is due to his genius(internal attribution). His genius is not limited to one field- he is generally the most valuable, productive and creative genius and is an all-rounder(global attribution). His genius is not a short-lived entity- he will continue to remain a productive genius no matter what external circumstances / reality (stable attribution). He may thus have no drive to learn about external reality as he suspects that the external reality is not relevant and he can predict outcomes (which are bound to be good) based on his skills, expertise, grandiosity alone. An extreme form of this thinking may lead to the loss of reality characteristic of a full blown Psychotic episode.

While the minimalisations and maximizations are explained by the internal locus of control, the over-generalization is explicable by a propensity of jumping-to-conclusions sort of thinking that leads to global, stable over-regularizations. Another feature important in my view would be the mixing of contexts, where things from one context are referenced in another, dissimilar context. One could call this mixing up of metaphorical thinking where wrong analogies are applied and thus wrong (positive or negative) conclusions are arrived at. The third factor of dichotomous thinking is also very important though hard to pin down. Why should everything appear black and white in depressive or manic thinking and why in one case(depressive ), black is the color of self, while in Manic white is the color of self, remains a mystery. Answering how and when the switch from a grayish-world to a black-me-world(I'm a piece of shit) or white-me-world(I'm the next Einstein) happens would go a long way in making the bipolar patient control his moods and if he has to be sick then enable him to go for a manic episode (where the price may be insanity- a psychotic episode) instead of a depressive one (where there is a real risk of life).

Although the other wrong attributions and thinking styles also need to be addressed, the mechanism of the switching of mood/ black-white world view would help the most and should be the first one targeted in CBT/ medications.


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16 comments:

Ricercar said...

hey! remember what we had talked about earlier? about autism and schizophrenia? someone at the lab is doing a study. not sure of teh details but its looking at the superficial similarities in social cognitive skill deficiencies in autism and schizophrenia patients and trying to prove that the underlying causes are different. I will try to get you more info if you are still interested.

Sandy G said...

Hi Ricercar,

I am definitely interested and would love to hear about the study. You can also email me at sandygautam17ATgmailDOTcom (remove Capitals).

Thanks for reading and remembering!!

DavidD said...

I'm sure CBT helps people with bipolar disorder. It helped me. But surely thinking is not central to the instability of being bipolar. Aren't the cognitive distortions of bipolars the same ones that human nature gives everyone? Why shouldn't one see distortions in bipolar disorder as something people reach for (or reject) when their mood is extreme for whatever chemical and/or neurophysiological reason it gets there, the same as people use or reject breathing, eating, sex, shopping, everything we can do? CBT helps me surf the waves of my emotions better, as many aspects of a healthy lifestyle do, but there's no way that's the most critical factor.

I remember my most depressed state and not being able to think at all. I remember my first mania, when for the only time in my life I experienced what it felt like to have absolutely no doubt. There's no way to think your way to that state - it's what some people take drugs for. Of course one's words are naturally distorted in such a state, but even then my words were much closer to normal than the feeling of it was. The feelings were unimaginable. If you allow that the thinking pattern is not central, then there's no mystery about why one is black sometimes and white others. The state is one of being extreme, not the individual direction. It's about labile emotion, not the message of either direction.

I'd love to know the neuroscience of such a transition. I doubt it's as simple as people think. It's too unnatural.

Sandy G said...

Hi David,

It was never my contention that bipolarity is primarily a cognitive disorder. We all know it is a mood disorder and involves extremes of heightened feelings/emotions and dysfunctional motivation system.

This post was more about what cognitive systems and attribution styles get affected due to vulnerability to bipolarity. It is instructive to note that while manic phase is marked by an extreme of our 'normal' self-serving attributional styles (good-due-to me; bad-due to environment) , the depressive thinking style is the inverse of the normal attributional style. In depression bad-is-due-to-me and good-may-be-due-to-luck/environment thinking is prominent and thus, ironically, in moderate depressive states we may be more prone to make more realistic assessment of ourselves and situations.

The other major point of my post was that things like over-generalizations,stable-generalizations and minimization/maximizations are not that prominent in unaffected individuls, but are more prominent in the bipolar spectrum.

Also, as you yourself have mentioned, and as research has proven, CBT or changing the thinking styles is able to treat depression/mania and thus their must be some cognitive basis for the continuation or downward spiral into the illness for affected individuals.

As to whether the switch from good attributions to self to bad attributions to self happens after the mood swings, or prior to that is a chicken-and egg question that needs to be settled.
One experiment that can throw light is putting normal people in happy or sad moods (by making them watch hilarious cartoons, or a holocaust movie) and then determining if this leads to biases in them towards the bipolar style of thinking: more over-generalizations, more stable generalizations etc. I suspect this could be the case and thus heightened emotionality- which leads to dysfunctional thinking style could explain the spiral into the illness or a relapse after an emotionally significant event (positive/ negative).

I further suspect that the stabilization of generalized beliefs (regarding self, regarding the external world out there) could be the prime cognitive factor, which when combined with heightened emotionality leads to a bipolar diagnosis. This I suspect as in mice models of depression, they are exposed to random shocks to make them depressed. After this they stop exploring the environment even when the shocks are no longer present. This is called learned helplessness. I prefer calling in learning helplessness as the stress of electric shocks would also affect neurogenesiis and atrophy of the hippocampal neurons and thus dispose them towards an inability to learn new things (about themselves/ environment) and thus they do not detect changes in external situations. The human equivalent would be forming a negative self-image (in an aversive situation that had also caused a mood swing towards the negative) and then not being able to modify that self image as the active, childish exploration of the environment has ceased. This may explain loss in activities like shopping, sex, food etc. In mania the opposite would happen, but here again the key would be that the good-belief-about-self would be stable and resistanty to external nullification.

I hope my position is clearer after this. Thanks for commenting and sharing your experiences with us and for giving me an opportunity to refine my thoughts towards the better.

Colin said...

ZAP! eek! eek!

Oh squeak is me. I am not smart enough to run this maze. In fact, I've never been good at these maze things. And look at my whiskers they're just ugly and ratty looking!

...by the way, nice summary of CBT.

DavidD said...

Sandy, thank you for continuing your remarks about cognitive distortions in bipolars. Do you notice that the attributional styles you mention are not necessarily different? You're describing that in both states the mood-congruent things that happen to me are due to me, while the things that clash with my mood must be from something outside. I don't know the literature enough to know - do some researchers see it that way?

I'm convinced that when bad things happen, it's healthy to blame oneself first, because I'm the one I can change the most easily. I'm sure a lot of any culture and superstitious behavior expresses that. Of course the reality of whether something is truly under my control and how much of it is under my control varies as widely as can be. It's good for us to learn that on top of our biological bias. I have thought it is our biological bias to blame ourselves first just from how much I see people do that and the superstitious behavior that accompanies that. I might have some sampling bias in my casual observations. I would wonder from the idea above that people embrace the attribution that is mood-congruent whether people blame themselves as much as they do because so many are walking around with some anxiety and misery rather than joy.

I see much overgeneralization and oversimplification of various types in people's opinions on the internet and in real life, enough so that I've thought cognitive distortions are common in most people. Of course, I don't know who's normal when I notice that. Does your statement that these are not prominent in unaffected individuals mean they are below some threshold considered "normal"? I'm sure those with severe moods have many more cognitive distortions, but I would see that as an amplification of what is in fact in us normally, just as mania can bring out intense color perception, but the colors are otherwise what they are normally.

All that being said, my guess still is that mania and severe depression intensify what we are normally, including cognitive distortions, except for the process that is at the center of the pathology, which I have a hard time imagining. I just know that I knew something of mania from my neuroscience training before I ever had a mania. It didn't prepare me for losing big chunks of myself, first doubt, then some memory, probably others that I have trouble labeling, then watching them come back over a matter of hours, sometimes as suddenly as if someone threw a switch. It is a strange phenomenon, but I don't find that cognitive distortions are strange. I'm not sure if it's best to call those childish, primitive or uneducated, but they certainly are common until people learn better.

DavidD said...

I was looking at your description of learned helplessness again, and it occurred to me that there's another way to see that. I understand the process you're seeing where someone attributes their helplessness to themselves, making everything worse.

Depression isn't always like that, you know. I was impressed that no matter how hopeless and helpless I felt, I never felt worthless. The depression always felt external to me. My first description of it to a doctor got me a thyroid test, not anything more insightful. Yet I had times of not being able to get out of bed that were as intense as almost anyone's. Of course everyone's different, but what are the dimensions of those differences? I would be surprised if there aren't different etiologies of mood disorders in different people, but it's still hard to talk about that today.

Anonymous said...

Isn't, then, depression and mania something similar to either lack of critical insight (as in, long-term memory blindness leading to fact selection bias) or lack of its effect on mood (ie. I know I should be happy, yet I am not)?

If hippocampus is related to storing configurations of stimuli, then damage to hippocampus may have an effect on fact selection.

I imagine, that our memory is roughly divided into "clusters" which are activated by different modulation systems (serotonin, sex hormones etc). When we, say, are hate-type thoughts about some person (ex-husband?) or are depressed or manic or sexually arosed, the modulation circuits (or their simplification/malfunction due to various factors) are blocking access to parts of memory which don't "agree" with our current "cognitive state" (mood or its generalization).

With clinical depression, the negative mood "hides" positive memories or the thought processes that lead from positive memories to positive mood, making the person think only of negative things, which strenghtens the negative memories, so they send "strong signals" even if modulatory mechanisms try to inhibit them. A positive feedback loop, which either ends with blowup (suicide) or saturation (persistent low mood). The same can be - probably - applied to mania, infatuation and other "blind" states.

How does the "switch" (mania to depression, love to hate) happen in such a primitive "model", then? I have no idea. Because it would require a strong/stable memory (manic) subset to fade instantly, giving he way to the competing, strong reverse (depressive) subset.

Posting as anonymous because of ranting factor (I don't know if what I'm saying isn't totally obvious or nonsense).

Anonymous said...

Typos typos...

giving he way -> giving the way
are hate-type thoughts -> are having hate-type thoughts

Sandy G said...

David, seeing the cognitive ditortions as mood congruent is a novel hypothesis;I'm not aware of any traditional interpretations of the cognitive distortions in these terms.

When bad things hapen, we blame the environment/ external factors. There is sound evolutionary rationale for why this should happen. In depression somehing opposite to this happens.There may be sound evolutionary rationale for that behaviour too in conditions when we have little control over a chronically stressful environment. Its sad that so many people today suffer from anxiety/ misery and thus may have undiagnosed depression which has milder symptoms but is long lasting (an episode lasting over years).

Cognitive distorions fall on a continum and what we call normal and abnormal is both culturally determined and detrmined from the perspective of adequate social functioning. I totally agree that the extremes are just a part of the normal continum. However as they lead to downwrad spirals in depression/mania, it is important to address them as soon as possible.

Cognitive distortions are not strage, but when addeed together and when all of them are towards an extreme end, they produce behaviour that seems starnge/abnormal.

As for learned helplessness or negative self-esteem attributions, there is fairly well documneted research that this is the case with depresion. Some people do feel worthless/ not in control. The negative attitude may be limited to negativity regarding the environment/ external situations, but due to low self-esteem (temporarily while suffering from dpression) those external negativities get amplified and seem intractable. Life seems not worth living.
Thus, I belive the need to adress cognitive distortions. Our thoughts nd attitudes are under our control and may provid us the neded respite.

Sandy G said...

Hi Anonymous,
You are not ranting and your comments make me and the mouse trap community see the depression/mania underlying distortions and pathology from a novel perspective.

Yes these cognitive distortions and lack of insight work in tandem with fact selcting bias and thus lead to either negative state (depression) when negative memories are accessed disproportionally; and mania when only positive memories are accessed.

As you pointed out why the switch from one cognitive set/ mood to other happens is the next million dollar question:-)

Indian Monsoon Boy said...

Hi Sandy

I read your post and must say that you have very good interests. While i was searching for the soul theory, the search engine located your blog too, so i got in.

Although, i am responding to enquire about something personal.... I would be glad to know about depression in women... for i have my mother, and a sis-in law who are moody and depressive and which sometimes becomes really bothersome.. Could you help me out in this.

Sandy G said...

Hi IMB,

I am glad that you liked my post.

A very informative link regarding the depression and women linkages is at NIMH site http://www.nimh.nih.gov/publicat/depwomenknows.cfm

I would recommend you to go over that. clinical depression should be taken seriously and the local psychiatrist consulted immediately. A mix of medications and therapy should help your mom and sis-in-law get overt their depressive episodes. You yourself can read some CBT literature and try to reason with them and show how their cognitive thinking style is doing them a disservice and needs to be replaced with a more optimistic and positive thinking style. And of course any environmental(social/psychological) stressors have to be addressed.

There are reasons why depression is more common in women (some of the depressive episodes are related to hormonal changes following menstruation, pregnancy etc) and I am afraid some reasons are still not clear. Its a complicated filed and maybe I'll do a post some day tentatively hypothesizing why depression is more common in women. That may lead to better treatment approaches. Till then take the help of local counselor, psychologist/ psychotherapist. We still do not know enough about the causes and how to prevent this, but we do know how to treat and keep the symptoms in check.

Indian Monsoon Boy said...

Thanks Sandy

I very much appreciate you reply. I hope you can postulate/opine on the topic very soon.

Thanks again

crispian123 said...

remember what we had talked about earlier? about autism and schizophrenia? someone at the lab is doing a study. not sure of teh details but its looking at the superficial similarities in social cognitive skill deficiencies in autism and schizophrenia patients and trying to prove that the underlying causes are different. I will try to get you more info if you are still interested.

=======================================================================

Clinical Depression

CRISPIAN

Sandy G said...

Hi ricercar, I am still interested.
Crispian123, that was a very cheap tactic to get your link (clinical depression) on my blog. If I see that haappening again, I;'ll be forced to report abuse and remove the link.