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Bipolar disorder is understood to exist on a spectrum of severity, with hyperthymic and cyclothymic temperament at one end of the spectrum and psychotic bipolar, or mood-incongruent mania, at the other end of the spectrum (Goodwin & Jamison, 2007). There have been numerous attempts to quantify the severity of symptoms on the bipolar spectrum. For example, Craddock, Jones, Kirov, and Jones (2004) created the Bipolar Affective Disorder Dimension Scale (BADDS), which includes plausible diagnostic criteria for situating mania and depression on a spectrum from mild to incapacitating.
While scales such as BADDS (Craddock et al., 2004) purport to measure bipolar disorder on a continuous scale sensitive to the spectrum, the scale for the administration of lithium to individuals with bipolar disorder is more uniform
in nature. According to Muzina and Calabrese’s (2005) discussion of bipolar treatment guidelines, the best practice is to administer lithium such that patients achieved a serum concentration of between 0.8 and 1.2 mmol/L. Thus,
as Van Calker and Berghofer (2010) have noted, lithium has a fairly narrow therapeutic range.
Lithium has not only a narrow therapeutic range, but also a long list of undesirable side effects, including tremors, nausea, and cognitive dulling (Keck & McElroy, 2010). In sufficiently high doses, lithium
is toxic (Van Calker & Berghofer, 2010). There is thus ample motivation for therapists, physicians, and other healthcare personnel to explore non- pharmacological treatment of bipolar disorder, in particular, given that there is limited research on the efficacy and risks of lithium for patients on the milder end of the spectrum (Van Calker & Berghofer, 2010) who do not suffer what Craddock et al. (2004) described as impairment
or incapacitation. Perhaps more controversially, it is also worth exploring the question of whether the relatively low success rate of bipolar treatment—both pharmacological treatment and existing
forms of therapy—is somehow associated with the inability of current treatment approaches to address the systemic features of bipolar disorder.
A systems approach to bipolar disorder could, in theory, function in distinct ways based on the observed severity of the disorder. First, for individuals
on the milder end of the spectrum, a systems approach to therapy could be a plausible first choice of treatment, to be supplemented with individual therapy and pharmacological therapy should the disorder prove to be resistant to
a systems approach. The theoretical argument in favor of such an approach
is that, for individuals on the milder end of the spectrum, the environmental component of the gene-environment interaction might be more determinative of the disorder. If in fact the environment is a dominant factor in the milder forms of the disorder, then a systems approach might be a better candidate for therapy. Systems approaches are highly sensitive to understanding and incorporating the environment, particularly the human environment, in treating bipolar disorder. Second, even individuals on the more severe end of the spectrum could benefit from increased attention to their human environments.
Bipolar disorder: Evolution of therapeutic thinking
Jean-Pierre Falret (1854) and Jules Baillarger (1854) separately defined bipolar disease (which Falret called
la folie circulaire and Baillarger called la folie a double forme) as a form of mental illness characterized by the succession of manic and melancholic states interspersed with periods of lucidity. Half a century later, Kraepelin’s (1904) case notes firmly established the existence of bipolar disorder in the context of modern psychiatry.
Kraepelin was seemingly oblivious to the intimate relationship between bipolar disorder and family circumstances. Introducing the case of one of his patients, Kraepelin (1904) wrote that “the
patient comes of a healthy family, but has a son who is insane” (p. 72). Kraepelin’s therapeutic blindness was remarkable; shortly after noting that this patient’s
son was insane, Kraepelin diagnosed the patient as having “groundless anxieties” (p. 72), as if the anxieties of a parent
with a mentally ill child could ever be groundless. Elsewhere in Lectures on Clinical Psychiatry, Kraepelin counseled that, for bipolar patients, “simple separation from others is an efficient calmative” (p. 66).
Lectures on Clinical Psychiatry reads like two parallel narratives, with one narrative being a demonstration of the existence of bipolar disorder and the other narrative being an inadvertent record of the systemic roots of this disorder, roots
that Kraepelin ignored. He provided
so many details of bipolar patients’ distressed family circumstances without ever connecting them—etiologically or therapeutically—to the disorder itself.
Bipolar disorder, like so many other forms of mental illness, was first treated in sanatoria (Roberts & Buikstra, 2012). Sanatoria were, of course, places in which the unwell could be segregated for treatment, but with little thought given to how the inciting sicknesses had been generated in society and would once again be subject to the pressures of society. Thomas Mann’s (2005) novel The Magic Mountain epitomized this concept of isolated, non-systemic, and ultimately bourgeois mental health treatment. However, even before the popularity of sanatoria as isolated treatment sites for mental illness, there was a long tradition of non-systemic approaches to bipolar disorder and its two components of mania and depression.
In Kraepelin’s work (1904), the diagnosis of bipolar disorder transferred all pathology and therapeutic attention
to the individual patient, who, once diagnosed, was subjected to a combination of warm baths, bromide of sodium, social isolation, bed rest, and, in general, “kindly, quiet, non-
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