Bipolar disorder is affected by psychosocial stress. Two domains have been studied: negative affective relationships within the patient's family, and stressful life events. Regarding the former, prospective studies indicate that bipolar patients who, following an acute illness episode, return to family or marital environments that are high in "expressed emotion" (containing relatives who are highly critical, hostile, or emotionally overinvolved) are more likely to relapse at 9-month or 1-year follow-up than patients who return to low-key family environments (for a review, see Miklowitz, Wendel, & Simoneau, 1998). It is not clear whether stress within the family is a primary eliciting factor for symptoms, whether bipolar symptoms in patients evoke family conflicts, or whether patients' symptoms and family conflicts are both traceable to third variables such as a shared genetic vulnerability to mood disorder.
Episodes of bipolar disorder often follow major life events (Johnson & Roberts, 1995). Various theories have been advanced for explaining this association. One model views the core dysfunction in bipolar disorder as one of instability and postulates that mood disorders are strongly affected by changes in the circadian clock (Ehlers, Frank, & Kupfer, 1988; Ehlers, Kupfer, Frank, & Monk, 1993). Life events that affect sleep/wake rhythms and other daily routines (e.g., the birth of a baby) do appear potent in eliciting manic, but not depressive, episodes (Malkoff-Schwartz et al., 1998). Another model postulates that life events interact with a faulty "behavioral activation system" that is sensitive to reward cues. Life events that involve goal striving (e.g., a job promotion) may stimulate this system, which then produces an aroused state associated with greater motivation for rewards, heightened affect, and increased sociability or risk taking (Johnson & Roberts, 1995; Johnson et al., 2000).
A third model, the "kindling hypothesis" (Post, 1992), postulates that bipolar episodes are often precipitated by an external agent (i.e., life stress) at the beginning phases of the illness, but patients become increasingly sensitized to stress over time. In later stages of the disorder, episodes occur spontaneously, without external stressors. Eventually the illness takes on an autonomous, self-perpetuating course. Evidence for the kindling hypothesis is inconsistent. Hammen and Gitlin (1997) found that among bipolar patients who had had recurrences, those with a greater number of prior episodes were more likely to have experienced a major stressor in the 6 months prior to their recurrence, and relapsed more quickly after the stressor, than patients with fewer prior episodes.
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