28 3 Family and Marital Therapy
This therapy included because as mentioned a little bit more before that family and marriage problem can be stressors in a patient’s life, in which the
correlation is those unpleasant life situations may cause the depression to relapse again and may require longer treatment. Therefore, the interference of family
member or spouse or couple needed to reduce the level of expressed emotion and to prevent recurrence. It is also suggested that for married people who are
depressed and having marital conflict can join this marital therapy, in which this therapy has been studied as well as cognitive therapy in reducing unipolar
depression.
7. Manic-Depressive Disorder Bipolar Disorder
a. Definition of Manic-Depressive Disorder Carson, Butcher, and Mineka categorize manic or mania and depression as
mood disorder. Kraepelin described the disorder as “a series of attacks of elation and depression, with periods of relative normality in between, and a generally
favorable prognosis” as cited in Carson, Butcher, and Mineka, 2000, p. 220. As mentioned before that manic-depressive disorder is the combination
between mania and depression. Therefore the meaning and concept of both can be recognized separately. It is stated that mania is characterized by strong and
unrealistic feelings of enthusiasm and euphoria. On the other hand, depression is a feeling of extraordinary sadness and dejection.
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29 In addition, they say that some people can experience these kinds of mood
disorder at one time, but others can only experience the kind of depression. When manic and depression occur in one time together, it is called bipolar disorder.
While, it is called unipolar disorder in the condition the individual only experience depression p. 210.
According to Wilson et. al. counter with Nathan, O’Leary, and Clark 1996, mania is viewed as people who are highly lively and impulsive, that
means when they are highly lively they become hilarious and entertaining. But then their mood and behavior can change spontaneously every time when they are
irritated with something. That means they are changeable or labile that gives effect to their performance. They also can interrupt other people’s business. For
instance, they move constantly, talk loudly and continuously, they have grandiose ideas, they go on a shopping spree, and even they do unrestrained sexual activity
p. 195. Wilson et. al. also add that a manic mood is unrealistically expansive, accompanied by the feeling that anything is possible.
According to Carson, Butcher, and Mineka, depression or called unipolar disorder is unpleasant feeling when we are in situation as sadness,
discouragement, pessimism, and hopelessness about being able to improve matters, but it usually does not last long p. 212. That means that feeling can be
experienced for some episodes, but then it goes for some moments. Then it can come and happen as the episode before. They also utter that the depression
involves facing images, thoughts, and feeling that one would normally avoid.
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30 They also state that depression is considered as normal if the depression is brief
and mild. Coleman, in addition, affirms that the influence of emotional mood
experienced by the manic-depressive or bipolar disorder can be the cause of extreme elation or depression p. 340. Hence, he also tells that extreme
depression or elation can give crucial effects for the individuals’ emotion or mood that also give side effect for their behavior disorder. Kraepelin also supports that
statement by describing the term of manic-depressive psychoses as “a series of attacks of elation and depression, with periods of relative normality in between
and a generally favorable prognosis” as cited in Coleman, 1976, p. 340. Commonly, that disorder rates experienced higher by female than male.
The most sufferers are group of people in between ages 25-65 years old. In addition, the children can possibly experience this disorder. Further, Coleman
explains that the patient of this disorder can experience many kinds of behavioral disorder, such as delusions, hallucinations, suicide symptoms, etc.
b. Factors Causing Manic- Depressive There are several factors in manic-depressive or bipolar disorder. The
factors are almost same as the unipolar one. Carson, Butcher, and Mineka 2000 state that the biological factors are clearly dominant, while the psychosocial
factors do not get much attention unlike the biological do pp. 243-250. 1 Biological
Causal Factors
a Heredity Factors
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31 The genetic component is significant role to bipolar disorder. It is stronger
in bipolar disorder than in unipolar. Carson, Butcher, and Mineka mention one study suggests that genetic material can influence the tendency of development of
bipolar disorder for about 80 percent. b Biochemical
Factors These factors related to the substance, such as drugs, which is used to treat
the manic-depressive patients. Whybrow explained that more recently it has been suggested that norepinephrine, serotonin, and dopamine are all involved in
regulating our mood states. Therefore, if the disturbances or disequilibrium exist in those balance neurotransmitters, it can be the main key why mood disorder can
cause mood or emotion up and down for the sufferers as cited in Carson, Butcher, and Mineka, 2000, p. 246. One issue that also stated by Carson, Butcher, and
Mineka reveals that lithium, the most effective and widely drug in the treatment of bipolar disorder, can stabilize individuals from both depressive and manic
episodes. c Other Biological Causal Factors
Goodwin Jamison and Whybrow also explain some significant considerations related to the disturbances in biological rhythms in bipolar
disorder. They give details that during the manic episodes of bipolar, the patients tend to sleep very little. While during depressive episodes, the patients tend to
sleep over hypersomnia. In addition, Whybrow puts forward that bipolar patients appear to be sensitive toward any changes in their daily phases as cited in Carson,
Butcher, and Mineka, 2000, p. 246.
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32
2 Psychosocial Causal Factors a Stressful Life Events
Johnson Miller propose a new study that finds the sufferers of this mood disorder who have experienced negative life events of their life, they need three
times longer to recover than those without having negative life events. They also make clarification why stressful events can affect and increase the chance of
illness to relapse. Since the effect of stressful events may give impact on biological rhythms, in which the biological rhythms give strong implication in
bipolar disorder as discussed before as cited in Carson, Butcher, and Mineka, 2000, p. 247.
Additionally, Swendsen et al also discuss the study that talks about the patients of bipolar disorder who are extremely introverted or obsessional tend to
be more responsive to stress as cited in Carson, Butcher, and Mineka, 2000, p. 248.
b Psychodynamics Views
In Carson, Butcher, and Mineka, psychodynamic theorists view that bipolar disorder as two different, but manic and depressive itself related each
other especially in defense-oriented strategies for dealing with severe stress. These theorists view the shift from mania to depression or vice verse. These theorists say
that “the shift from mania to depression may tend to occur when the defensive function of the manic reaction breaks down. Similarly, the shift from depression
to mania may tend to occur when an individual, devalued and guilt-ridden by
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33 inactivity and an inability to cope, finally feels compelled to attempt some
countermeasure, however desperate”. Coleman 1976 in his Abnormal Psychology and Modern Life book also
support that statement and further he also explain how the sufferers of manic- depressive disorder try to defense themselves from the mood disorder they feel
pp. 354-355. He says that in case of mania, the sufferers will tend to have tremendous energy to deny their feelings of helplessness and hopelessness and
they will do many activities, such as go around of parties, do restless activities with work, athletics, sexual affairs, and other crowded activities with aim to try to
forget the incident or threatening life situation they experience. While, the patients experience depression, they tend to blame themselves for the difficulties that
happen in their life. They often look and recall at their past and they even accuse themselves of selfishness, unfaithfulness, and hostile acts that did not occur.
3 Sociocultural Factors
a A Belief in Self-Sufficiency Carothers has observed and studied that in rural area the societies tend to
experience manic disorder, dissimilar with the modern area in western societies where the societies tend to experience the depressive disorder. That can happen
since the societies who live in rural area, they are not personally responsible for failures and misfortunes. That is contrary with modern societies who have highly
problem and responsibility for self-sufficiency. In Carothers’s view, it told that their behavior was largely group-determined, and therefore they were not
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34 confronted with problems of self-sufficiency, choice, and responsibility, which are
so prominent in Western cultures as cited in Carson, Butcher, and Mineka, 2000, p. 249.
b Demographic Differences in Societies There are many studies that show that bipolar disorder is more common in
the higher socioeconomic classes. It is also shown that the individual of bipolar disorder come from families with higher status and tend to have more education
than do the unipolar one. The relation of that bipolar and higher socioeconomic status is perhaps the bipolar leads to increase achievement and accomplishment.
The evidence of that case can be seen from some occupation, such as poets, writers, composers, and artists.
c. Kinds of Manic-Depressive Psychoses Within the study of manic-depressive psychoses, there are some subgroups
namely manic and depressed types. Each of them has subgroup, as Coleman 1976, pp. 341-347 mentions as follow:
1 Manic Types
Coleman defines that this manic types characterized by variety degrees of elation and psychomotor overactivity. Those degrees categorized from the mildest
to extreme degrees. They are defined as follow: a Hypomania
This is the mildest type of manic reaction. This mildest type is described by medium elation, inconsistency, and overactivity. The individual who
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35 experiences this type commonly feels great, he has unlimited confidence in his
ability and knowledge, and he also without doubt and quickly express his opinion on all subject. He thinks speedily and he may particularly become amusing and
entertaining person. The person also feels tireless that he acquires mostly no sleep and feels that he does not need anything. He has many continual activities to do
during the day, such as talking, visiting, keeping luncheon and other appointments, telephoning, writing, and working on various sure-fire schemes.
For the overall depiction, Coleman further reveals that in the beginning the person seems to be an aggressive, brilliant, sociable individual who has many
worthy enthusiasm and great plans for the future. At first, he is an exciting person to be with, but then he soon shows his self-centeredness, becomes dominant,
monopolizes the conversation, and shows difficulty in sticking to the subject. He cannot accept or intolerance of any criticism and he even denounce as stupid fool
people who disagree with his opinion or idea and also who interfere with his plans. In addition, he is ready with a rebuttal to against people who dare to
interfere or criticism his business. He also seldom makes his plans happen and very few of his plans are ever put into action. For his plans or activities to be
done, he easily rationalizes them and also admits no mistakes. He spends money recklessly and in a short period of time he may waste his entire savings.
b Acute mania
This second type of manic reaction characterized by elation and pressure of activities become more obvious and he may laugh boisterously and talk at the
top of his voice. He becomes the person who is increasingly boastful, dictatorial,
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36 domineering, and may command everyone around him as if he is a super dictator.
His bad temper is easily irritated anytime and his mood can change quickly from fun to anger. Both before and during hospitalization, brutal behavior is commonly
showed. He may breaks up the furniture or things around him, defaces the walls, and attacks nurses and other patients. He is continually walking back and forth,
gesturing to himself, singing, and slamming on the walls and door, demanding release.
Further, the individual has a wild flight of ideas. His speech becomes incoherent and cannot be comprehended. There may be some confusion and
disorientation for time, place, and person. He presents temporary delusions and hallucinations, in which he hallucinates about the grandiose ideas of his wealth
and abilities or he may hallucinate that he hears voices and do conversations with person whom he imagines to be present.
c Delirious mania
This is the most dangerous, severe, and extreme type of manic reaction. The characteristic of this kind of manic reaction are the individual is confused,
wildly excited, and also brutal. He shows so incoherent and disoriented, that it is difficult to have conversation with him or hold his attention. He may experience
vivid auditory and visual hallucinations. He also shows his restlessness by behaving like singing, screaming, gesturing, and incoherent shouting. His
condition of personal habits totally gets worse. It is unsafe to be close with him since he may seriously injure himself and others. He also loses his weight quickly
and become fully fatigue.
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37
2 Depressed Types
In this depressed types, there are also three different degrees that reverse from the types of manic reaction. They are:
a Simple depression
The person who suffers this type of depression commonly has loss of enthusiasm and hopelessness. Further, his mental and physical activity reduce
becomes slow down. He mostly feels unhappy and depressed. His feelings of unworthiness, failure, sinfulness, and guilt can affect his thinking process that can
cause his thinking slow down. He needs super and more energy to do his usual work and activities. Therefore, it can make him less interest of his usual activities.
It can also give effect to his appetite that makes him lose of weight and gets digestive difficulties, such as constipation. He converses in monotone and answers
questions with very little supply of words. Generally, he chooses to be alone to think what he has done, which may be all of his sins, and his despair affect him to
see no hope for the future. He also thinks about suicide and attempts to make it happen.
Many of the patients of this depressed type still have awareness to understand their real condition and they can realize that they need treatment. But,
generally they will emphasize and admit that the cause of requiring the treatment not because of depressed but because their various bodily illness, such as
headaches, fatigue, and loss of appetite, constipation, and poor sleep. They also
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38 will confess and think that the cause of being that because of their various sins and
mistakes in their past. b Acute
depression The person who suffers this acute depression commonly becomes more
inactive, tends to separate himself from others, does not speak in unity so it is difficult for others to have conversation with him, and increasingly very slow in
his responses. He shows more feelings of guilt and worthlessness. He may feel guilty and think that he is responsible for everything bad or disaster that happens
in his surrounding, such as disease, floods, or economic depressions and it happen because he thinks that he has done something really terrible that will bring disaster
for everyone. He will refuse to eat. For the wrong things that happen in his life, such as his health, he will blame these ailments for the cause of making them. He
sees absolutely no hope to make better the things that he has done. The individual also feels the unreality and mild hallucination correlated to sin, guilt, and disease
may occur generally. The consideration of suicide is also occurring since it seems as the only way to out.
c Depressive stupor
This type is the most severe and extreme of depressed type. It is stated that the person who suffers this type becomes totally unresponsive and inactive. He
just prefers to put his body down on the bed and will speak not coherently to all that exist around him. He refuses to eat or speak. He is also confused about time,
place, and person that appear close to him. The dramatic hallucination and
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39 delusions, particularly involving imagination about sin, death, and rebirth, may
occur.
d. Symptoms of Manic-Depressive According to Alloy, Riskind, and Manos 2005 the opening of this
disorder started by manic episode may be followed by a normal period, then by a depressed episode, a normal episode, and so forth p. 251. Cusin, Serreti,
Lattuada, et al. support that idea the episodes in bipolar disorder are commonly briefer and more frequent as cited in Alloy, Riskind, and Manos, 2005, p. 252.
Carson, Butcher, Mineka explain that depressive, manic, or mixed of them is classified as the episode of this disturbance. Even though a patient may show
only manic symptoms, bipolar disorder must exist, and the depressive episode definitely will appear. It is also stated that there are no commonly for only
unipolar manic occur, it must be a part of a bipolar disorder, or perhaps this mania occurs along range on which depression and manic exist pp. 220-221.
The diagnosis for individual who experiences bipolar disorder can be misdiagnosed at first since his or her initial episodes are depressive. The person
can be diagnosed as bipolar if he or she exhibites the signs at least one manic episode in the past. Carson, Butcher, and Mineka view that such misdiagnoses are
unfortunate and important since the treatments are different unipolar and bipolar disorder. One terrible effect of misdiagnosed is it can make worse the course of
the illness p. 223.
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40 In addition, Cassidy et al. reveal that “a recent large study of 237 manic
patients also revealed that during manic episodes some patients also report intermixed symptoms of depressed mod, anxiety, guilt, and suicidal thoughts”.
Leibenluft also adds that “mixed episodes seem to be more common in women than in men” as cited in Carson, Butcher, and Mineka, 2000, p. 221.
Further, they also state that manic symptoms in bipolar disorder are extreme and it can give significant damage of occupational and social functioning
for person who suffers it. Commonly, the person will show the symptoms that his mood is elevated, euphoric, and expansive. In addition, the patient’s activity
increase significantly and mental activity speed up that can cause he may experience a “flight of ideas” or thoughts that pass rapidly through the brain. He
may get high level disturbance of verbal output in speech or writing and also the disturbance in sleep also occur that he will sleep decreasingly. Then, his
confidence also increases highly. When severe becomes delusional, the person will experience the feelings of enormous greatness and power. His delusional and
feelings that then make him will attempt to take foolish risk with a high potential painful results, such as foolish business project, sexual indirections, etc 221.
Same as unipolar disorder, the range of this disorder start from the mildest to moderate and then to the severest p. 219. The range from mild to moderate is
known as cyclothymia. The pattern of cyclothymia is less serious and no extreme symptoms and psychotic features, such as delusions, occur.
Alloy, Riskind, and Manos give some hints about the characteristics of manic-depressive or bipolar disorder p. 252. First, bipolar disorder happens in
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41 the two sexes with approximately equal frequency and is more common among
higher socioeconomic groups. Second, people who experience bipolar disorder are more likely to have a history of hyperactivity. Then the third is it creates great
destruction and has bad long-term outcome. In addition, generally manic- depressive often develops more quickly and briefer.
f. Treatments and
Outcomes Since wide variety of treatments for this disorder are available today, and
while manic and depressed patients suffers huge amount of personal suffering and they also lose their productivity, their awareness to heal that illness by treatments
are increasing greatly. Carson, Butcher, Mineka mention those treatments and outcomes for the sufferers of bipolar disorder p. 253
1 Lithium and Other Mood-Stabilizing Drugs Lithium therapy is a kind of drugs used for both depressive and manic
episodes of bipolar disorder. The name of mood stabilizer is often used to label these drugs since these drugs have both anti-manic and anti-depressant. The using
of lithium can help in reducing both the episodes of manic and depressive, but not for those who stop using these drugs. These drugs also have an unpleasant side
effect, such as lethargy, decreased motor coordination, and even the using in long time can cause kidney malfunction and sometimes a permanent kidney damage.
Many patients state their problems of using these drugs. They say that the using of lithium can cause them lose high energy that associated with their
hypomanic and manic episodes. Therefore, an additional drug also added, which
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42 is anticonvulsants. These drugs are also useful and more effective for those who
cannot respond well to lithium and cannot accept well the side effects of it. 2 Electroconvulsive
Therapy ECT can also be used for the treatment of manic episodes. There is an
evidence shows that for about 80 percent of manic patients exhibit the indication of reduction and improvement. In addition, it is also noted that the use of mood-
stabilizing drugs followed by ECT can help the reduction or prevent relapse. 3 Family and Marital Therapy
For bipolar disorder, this kind of therapy combine with medication significantly can help in reducing relapse. This therapy needs the interference of
family members or spouse. Their help and support is needed orderly that the sufferer can be recovered in a short period of time.
B. Theoretical Framework
