[Music] hi and welcome to another video from the seag clinic my name is Dr Mike Lloyd and I'm the clinic director in this video we're going to be continuing the series on conditions associated with dissociation we're going to be focusing on bipolar disorder now this used to be called manic depression in the old days and and now it's bipolar disorder and there are a number of different types to it and what we' be doing is just having a general look at what bipolar is and then looking at some of the links with dissociation and then maybe some of the common iology between the two I.E what might be causing these conditions to be present in the same place so to start with we'll look at the dsm5 classification of what bipolar disorder is and we can largely look at it by thinking about it in these terms the bipolar disorder is a group of brain disorders that are categorized by Extremes in uh functional ability and mood and energy so the these are disorders of the brain as far as we can tell looking at that definition there are three different categories or subcategories of bipolar disorder that's bipolar 1 bipolar 2 and cyclothymic disorder and here's some background on exactly what those three things are so bipolar one is a seen as a manic depressive type disorder that can exist both without and with psychotic episodes bipolar 2 is again oppressive and manic episodes which alternate less severe don't really inhibit function and then the cyclothymic is a cyclic type disorder that causes brief episodes of hypomania and depression and what we see is that within bipolar disorder there can be these periods of sort of great excitement or activity delusions or Euphoria which would be the sort of the manic side of things and then if we're thinking about the depressive side of things it's sort of like great periods of sadness and hopelessness and often in clinical practice what we see is there's sort of the depressive symptoms last for a long time the manic symptoms last for more acute periods of time and those are the ones that often bring people into contact with Services because the the overactivity the driven quality of those manic symptoms are the things that really do cause people a lot of distress lots of problems and and can really sort of attract the attention of services and worry and concern from friends and family in terms of prevalence rating some of the statistics are around about bipolar being in to say 2.5% of the general population so that's quite a big number lots of people do um seem to have bipolar as a condition and obviously it does vary in in in severity in terms of what a person might be experiencing and there are treatment Pathways for this so it is is quite a a condition that has a reasonably good treatment outcome and the the diagnostic criteria for this is largely dependent on sort of Fairly standard features so there's a list of sort of diagnostic criteria which we'll look through and then it comes down to sort of the intensity the frequency and the duration of these so to look at something like say bipolar disorder versus say something like borderline personality disorder is often looking at the the length of time that the s that the symptoms can last for so whether or not there's a sort of the imbalance or the frequency the upturn of the manic depressive symptoms is occurring over a long period of time or a short period of time I minutes as opposed to weeks can lead someone to you know one diagnostic criteria rather than the other when we're actually looking at this clinically but we're focusing really on the bipolar side of things here so we're looking at sort of Fairly intense uh symptoms that have quite a long duration and and that will qualify for the diagnosis as long as the following things are present and I'll put up a screen just to show you exactly what the diagnostic criteria is and that's coming up now [Music] okay so that's looked at both the manic side of things the sort of the behavioral symptom dysfunction type things and then the sort of the more depressive qualities of that so that's fine so we know what bipolar is it's very well researched it's very well treated it's very common and I've had 10 years of experience working in Mental Health Services with adults and we saw an awful lot of people with bipolar disorder it's a very common condition seen in the psychiatric population one of the things we then need to think about is sort of well how does dissociation fit into this and there is this thing that is known as bipolar dissociation and what is seen is that actually the symptoms of dissociation are seen to be present in many many people that present with bipolar symptoms so we're seeing sort of an overlap between the two things a lot of people with bipolar also have dissociative symptoms and generally it's considered within this is that the dissociation is sort of secondary to the bipolar I.E the person is experiencing bipolar and as a result of that they then have a sort of a set of dissociative type symptoms presenting so the the cause if you like of the dissociation is coming out of the sort of the extreme bipolar dysfunction and again I'm going to put up a a screen which shows an outlines really what the major sort of bipolar dissociative symptoms are about disconnection dreamlike States the concentration the the Detachment we've got memory loss and we've got some of those things about time and disorientation kicking in there so a lot of these things are exactly the same as we see when we're actually we're actually diagnosing dissociation in a sort of a complex toring dissociation population as seen within the CAC clinic so the dissociative symptoms that are present within the bipolar and are known then as bipolar dissociation are fundamentally correct to be known as dissociative symptoms so we're completely fine with that what we got to try and do is sort of break down the sort of the links between these and work out exactly how common this is and there has been some research on this but not a great deal it's an awful lot of research in bipolar disorder but really not very much in terms of the link between bipolar and dissociative symptoms occurring in the same person but we do have some so I'm going to look at a little bit of the research around this so steo and Al in 2021 they found in in only using a fairly small Sample about 100 people take part in that sample with bipolar is that there was a link between bipolar and dissociation so that they clearly found that quite a few of those bipolar patients did also have dissociative symptoms but the interesting thing is that they noticed that the people that had those dissociative symptoms within the bipolar presentation had a lower response to treatment I.E the treatment that was given to people with bipolar was less effective for those people with dissociation so somehow the dissociation got in the way of the bipolar treatment being successful Raj Kumar in 2022 did a larger review we found out that actually the number of people with bipolar dissociation was running between 10 and 30% so that's up to nearly a third of the population of people in a larger sample group on a review article had dissociation alongside the bipolar that's a lot of people this was also seen in tekken's 2019 study where he found that about 35% of the people with bipolar also had dissociation and of those people with dissociation the largest um single type of dissociation that was seen was depersonalization which is running about 17% so we've got some really clear evidence here that high numbers of people with bipolar also have dis dissociation hence why we think of this term as bipolar dissociation but I really don't think many people know about this as I've said 10 years working in cmhts lots of bipolar patients throughout our case loads and I don't remember any of them being screened for dissociation or dissociation being mentioned at all in the pathway of treatment that we had now that's not a failure of services it's just a sort of a lack of understanding or appreciation about what's being seen and I think bipolar is one of those classic conditions where if we start treating the bipolar that becomes the because it's a highly psychiatric lead treatment it's a very very clear setout pathway within the NHS it's quite often medication orientated there are some sort of psychological factors that can come into play to assist people with their bipolar managing symptoms managing uh emotions fluctuations change of effect and sort of treatment and you know sort of regimes being complied to but there's really lack of dissociation actually being mentioned at all and I don't think anyone's really being screened for this on a reg basis so I would definitely be recommending that people with bipolar are screened for dissociation because if the research is showing that around a third of the bipolar patients are likely to be dissociative they absolutely need to be screened for dissociation because if the treatment is not taking dissociation into account the dissociation is likely to get in the way of a positive outcome for recovery and that's significant stuff that means a lot of people are potentially being treated and their treatment is not as effective as it could be because something is being missed on that treatment pathway so we know that bipolar dissociation exists and we know that the presentation of dissociation within bipolar is exactly the same type of stuff that we see when we're measuring dissociation in a in a traumatized population ah there we go right so there's the word trauma so we need to tr really understand is the dissociative symptoms in bipolar dissociation that built into bipolar so the bipolar is causing the dissociation or is something else taking place that's a really difficult thing to do because this is again a very poorly researched area what we can do then is think about the cause of both we know that dissociation is based on childhood trauma so the highest risk factor that we possibly have for person developing dissociation later on in life is a history of childhood trauma the adverse childhood experiences if a person has a lot of child of trauma or the risk factor is greater for dissociation there are many protective factors not everyone does become dissociative obviously but the risk factor is higher so then we think well okay what's going on with bipolar what do we know about the cause for bolar and that's where things get really really interesting because some of the articles that I've mentioned in the history taking that they've done of the participants in those studies also noticed that there was for quite a large proportion of them a history of childhood trauma so they're seeing childhood trauma in people presenting with bipolar disorders and actually there's a really interesting study in 2016 where from us Henry and Andreas and others that demonstrates a clear link between the causation of bipolar disorder being related to Childhood trauma and actually what they said there is that childhood trauma was a significant risk factor for developing bipolar disorder later on in life so in some respects we can almost predict that people that are presenting with childhood trauma might well go on to end up being diagnosed with bipolar disorder and about a third of those are going to be dissociative and here are some of the types of things that crop up from childhood trauma that we also see cropping up within dissociation and I'll just read these out on the screen the childood trauma can lead to alterations of affect regulation impulse control and cognitive functioning which reduces the ability to cope with stresses and this is really interesting stuff so we then we know that childhood trauma can lead to dissociation and we know that childhood trauma can lead to bipolar disorder and that bipolar disorder is also linked to dissociation in about a third of those people I mean this is really powerful in terms of what we actually take from this because the question that I then come to with this is well are we then seeing bipolar dissociation as a sort of like a subcategory of dissociation or actually are we seeing those as being two completely separate comor coorbit conditions that are existing in the same person so the person both has bipolar disorder and they have dissociation and those are separate conditions in the same person and if you ignore one and only treat the other you're in trouble so if we only if we only try to if we only treated and diagnosed and treated dissociation we ignore the bipolar disorder there's a lot of problems organic problems in terms of the fluctuation of that person's Mania and depressive states that we wouldn't be taken into account and we might be misordering those in terms of what we think that's going on and the reverse is also true if we treat the bipolar disorder ignore the dissociation the person's less likely to become well and that's simply what is known in research to conclude then I think it's pretty clear that the the the research is and our clinical evidence realistically is pointed towards the same sort of thing that bipolar disorder and dissociation are heavily linked with each other they both have a very similar cause in childhood trauma and that one is existing in a great number of patients alongside the other and then the other thing that we know clinically is that I don't think people are taking the two of them into account in the same time so my advice really for health services and clinicians if that you have a patient who has bipolar disorder is do a simple screening test using the dees2 to actually look and try and see whether or not there are dissociative symptoms present so doing the dees2 it's a 28 point questionnaire it can lead you to have an understanding where the dissociation is present and that might also help people understand why some of the treatment Pathways for bolar disorder is not as successful as they could be so we do see these I think as a comorbid condition that the two are coexisting in the same person at the same time and yet one I I think is being prioritized over the other and both need to be taken into account so I really hope this video has been helpful it's a it might be a really interesting video for anybody with bipolar disorder who really just wants to know a little bit more about the condition and might be asking why they have these other effects taking place that aren't really in the obvious list of bipolar symptoms and it can magnify the effect of any of those symptoms and it can reduce quality of life and it can reduce the uh likely treatment effect taking place so it can make that recovery can be high harder thing to achieve so I'd really be interested in in receiving and listening to your comments in the in the Box uh underneath the video and we'll keep producing videos so do all the usual stuff like subscribe please share these videos as widely as you would like to I think it's really great that people are doing so and I'm really really happy that that's the case and we'll keep producing videos and we'll continue with this series for the time being um so in between now and the next video please do take great care