02.04.2025 Between highs and lows

A life between extremes - Prof. Dr. Dr. Michael Bauer investigates bipolar disorder as part of the SFB/TRR 393 and sheds light on the subject

The WBD is a collaborative initiative of ISBD, IBPF, and ANBD.

On Sunday, March 30, the World Bipolar Day, the focus shifted to an disorder that is often misunderstood. Characterized by extreme mood swings between highs (mania) and lows (depression), bipolar disorder affects millions of people worldwide. But how does it feel to live with this diagnosis? What progress has been made in therapy research? Researchers in the Collaborative Research Center SFB/TRR 393 are working on diagnosis and therapy. We asked the local spokesperson of the TRR 393 site in Dresden Prof. Dr. Dr. Michael Bauer, Chair of Psychiatry and Psychotherapy at the University Hospital of the TUD Dresden University of Technology.

The term “bipolar disorder” sounds dramatic and definitive - what exactly does it mean? 

Bipolar disorders are diseases with severe mood swings that are characterized by the repeated and usually lifelong occurrence of prolonged affective episodes called depression and mania. As these two types of episodes, or poles of the disorder, have opposite, mirror-image symptoms, they are now referred to as bipolar disorder. Since it was first described scientifically around 120 years ago by the German psychiatrist Emil Kraepelin, this clinical picture was referred to as manic-depressive illness until the 1980s, a term that is still widely used by the general public and in the media today.

In bipolar disorder, the patient's mood fluctuates between extreme phases of highs and lows. The disease is diagnosed when there is at least one depressive and one manic episode. There are usually a large number of episodes over the course of time. Both poles are characterized by a variety of symptoms, which are sometimes more or less pronounced in those affected. Typical symptoms of the depressive phase include a depressed, downcast mood and even suicidal thoughts, loss of interest and drive, joylessness, loss of appetite and libido and sleep disorders. Mania is typically characterized by an elevated or alternately irritable mood, increased drive and restlessness, an impulsive and risky lifestyle, increased speech, increased and wasteful spending and a reduced need for sleep. Both depression and mania can also lead to psychotic experiences with delusional thoughts and hallucinations if the symptoms are severe.

The disorder occurs in one to two percent of the population in all cultures, social classes and societies. In Germany, it is estimated that around one million people are affected.   

How does bipolar disorder affect the lives of those affected and those around them?

Depending on the severity of the disorder - i.e. the severity, duration and number of episodes - bipolar disorder has a serious impact on the lives of those affected: Dropping out of school or training, unemployment, early retirement and high levels of relationship break-ups are much more common than in the healthy population. This means that the immediate environment in the circle of friends and family is also exposed to considerable stress.    

The consequences can be serious: Dropping out of school or training and studies, loss of employment, social withdrawal and separations from partners, to name the most important. 

Relatives and friends play an enormously important role in recognizing and coping with the disorder. In psychoeducation, not only the patient but also their relatives should receive information about the disease, the various explanatory models and treatment strategies. One focus is the prevention of relapses, where acceptance of the disorder and insight into taking preventative medication are of great importance. The better informed the patient and their family are, the better the cooperation and acceptance of the disorder. The development of stress factors and possible coping strategies are also part of psychoeducation, as well as learning self-observation and the ability to recognize early symptoms in good time and, if necessary, to carry out appropriate crisis management. With the help of psychotherapy and psychoeducation, it is possible to lead the patient and their family to a better understanding of the disorder, reduce stressors and learn coping strategies for dealing with the disorder. Structuring the day, planning activities and regeneration phases and learning ways to relax are other important topics.

What does science know about the origins of bipolar disorder?

Scientists still do not fully understand what exactly changes in the brain in bipolar disorder. What has been proven is that genetics play a major role. Children of bipolar people have a ten times higher risk of also developing the disorder. Nevertheless, bipolar disorder is not a hereditary disease. It is only triggered by a combination of external environmental factors. Traumatic experiences in early childhood, extreme stress or even drug abuse can act as triggers if the person is predisposed. It is now assumed that the heritability, i.e. the hereditary proportion of the variability of a phenotypic characteristic of a multifactorial illness, is 60 to 80 percent, meaning that 20 to 40 percent is due to environmental factors that determine whether someone becomes ill or not.

Despite the high heritability, most of the underlying genetic determinants are still unknown. An international team of researchers, including scientists from the three sites of the Collaborative Research Center/Transregio 393 (SFB/TRR 393), analyzed data from 158,036 participants with bipolar disorder of European, East Asian, African American, and Latino ancestry compared to 2.8 million controls, combining clinical and self-reported samples. The meta-analysis with multiple ancestry groups identified 298 genome-wide significant gene loci, a fourfold increase over previous results. Several analyses point to the involvement of specific cell types in the pathophysiology of bipolar disorder, including GABAergic interneurons and medium spiny neurons. Taken together, these analyses provide additional insights into the genetic architecture and biological basis of bipolar disorder.

What progress has been made in therapy?

With the right treatment, a normal life is possible for many patients. Lithium is a key medication and has been the “gold standard” for preventing episodes of the disease for over 60 years. The light metal and chemical element of the periodic table is also found as a trace element in drinking water, although the therapeutic dosages used are much higher than in drinking water. Although it is still not known exactly how lithium works, around a third of patients respond optimally to lithium and can lead a symptom-free life without additional measures. Another third experience considerable improvements. The remaining third do not respond or respond only insignificantly. Alternative medications, of which there are several, must then be tried one after the other. Unfortunately, no new promising drug options are currently expected in the immediate future.

In addition to drug therapy, additional treatment with psychotherapy has become established and proven successful over the past twenty years, which is also reflected in the treatment guidelines. 

The aim of psychotherapy for bipolar disorders is to influence the various disease factors, in particular to recognize stressors in good time and to deal with emotional problems of the disease, fear of a new relapse, issues of stigmatization due to the disease as well as social consequences and impairments in psychotherapy. The focus is on regulating social rhythms. Various psychotherapeutic approaches such as interpersonal psychotherapy, cognitive behavioral therapy and family therapy methods are used.

As already mentioned, it can be assumed that there is not just one cause for the development of bipolar disorder, but that various biological factors, in particular genetic factors, and environmental factors, in particular stress factors, interact with each other. A so-called “vulnerability-stress model” can be assumed, which means that genetic predispositions for the development of bipolar disorder are interlinked, but the disorder only breaks out if unfavorable life circumstances lead to a considerable stress situation and then the disorder breaks out if the brain is susceptible to certain stressors.

An understanding of this “vulnerability-stress model”, which can be taught and learned as part of psychotherapeutic and psychoeducational therapies, can often help sick people to better influence their disorder by trying to recognize stress factors individually and minimize them.

How do those affected learn to live with the disorder?

Bipolar disorder can lead to considerable impairment of quality of life, especially psychosocial development, so early detection of this disease and early initiation of treatment are extremely important.

The disorder often begins in young adulthood, i.e. in a phase in which important steps are still being taken for further life planning - e.g. school and training.

It is not only the affected person who is considerably affected by this disease, but the entire family. It is therefore important to recognize the first signs of a phase of the disease - so-called early warning symptoms - so that appropriate countermeasures can be taken and therapeutic interventions can be initiated.

What stereotypes are there about bipolar disorder - and how can we overcome them?

As with all mental diseases, despite all the anti-stigma campaigns by relevant professional organizations over the past two decades, there is considerable stigma about bipolar disorder in the general population. Evidence suggests that initiatives to reduce stigma are more likely to be effective when tailored to the clinical profile of specific disorders, but few specific stigma interventions have been developed for bipolar disorder. Although most modalities of psychotherapy for bipolar patients address aspects of internalized stigma, their anti-stigma efficacy is unproven. Meanwhile, in the clinical characterization of bipolar disorder, all affected individuals should be asked about internalized stigma and its impact on the experience of mental illness, overall functioning, compliance with treatment, and motivation to participate in treatment for the disorder. 

Stigma is described as consisting of two elements: public stigma and internalized stigma. Internalized stigma refers to the negative self-perception of people with mental diseases. Internalized (self-) stigma refers to the internalization of social attitudes and discriminatory practices. It is defined as a subjective state that is “characterized by negative feelings (about oneself), maladaptive behavior, identity changes, or the confirmation of stereotypes that result from a person's experiences, perceptions, or anticipation of negative social reactions due to their mental illness. Self-stigmatization has a serious impact on the lives of people with mental disorders and their families. It can be associated with withdrawal, social exclusion and a reduced quality of life. In some cases, internalized stigma or self-stigma prevents people from seeking treatment or is an obstacle to optimal treatment.

The questions were asked by Martin Schäfer.