Elsevier

Psychiatry Research

Volume 219, Issue 2, 30 October 2014, Pages 248-254
Psychiatry Research

Review article
The role of social relationships in bipolar disorder: A review

https://doi.org/10.1016/j.psychres.2014.05.047Get rights and content

Highlights

  • We reviewed literature regarding social relationships and bipolar disorder.

  • We use the Social Convoy Model to conceptualize these relationships.

  • The literature is bare and inconsistent but shows the importance of relationships.

  • We argue for more research in this area.

Abstract

Social relationships and attachment are core developmental elements of human existence and survival that evolve over the lifetime of an individual. The internal and external factors that influence them include the presence of illness in the individual or in their immediate environment. The developmental aspects of attachment and social relationships have become increasingly of interest and relevance in light of early developmental epigenetic modification of gene expression patterns that may influence subsequent behavioral patterns and outcomes. This review examines extant literature on attachment and social relationships in bipolar cohorts. Despite many methodological challenges, the findings indicate that social relationships and capacity for attachment are significantly compromised in individuals with bipolar disorder compared to other mood disorders and normal controls. Though extant research is limited, research clearly points toward the importance of social relationships on the etiology, course, and consequences of bipolar disorder. We highlight a number of key considerations for future research.

Introduction

Studies examining social relations among individuals with bipolar disorder diagnoses suggest that these individuals are more likely to report insecure attachment relationships and poor social support. This association may be highly relevant for the individuals’ course of illness and life trajectory, as studies in the general population have shown that supportive relationships may buffer against life׳s stressful experiences. This paper comprehensively reviews the literature on the role of social relationships in emotional wellness across the life cycle in persons with bipolar disorder. The data presented are organized in the framework of Social Convoy Theory.

Bipolar disorder is characterized by a lifelong pattern of pathological mood swings ranging from the energized states with misguided volition and intoxicating euphoria (or irritability) of the manic phases, to the spectrum of depression with compromised energy, volition, and slowed cognition, concentration, and physical activity. There are overt and covert debilitating consequences, socially, personally, and vocationally, placing bipolar disorder among the top ten causes of years lost to disability (Murray and Lopez, 1997). Even euthymic and remitted bipolar individuals report lower functioning and well-being compared to patients with chronic medical illness, major depressive disorder (Cooke et al., 1996), or the general population (Arnold et al., 2000). Two years following the first onset of bipolar mania, only a third of individuals return to their former level of functioning (Tohen et al., 2000, Duffy et al., 2007).

Individuals with bipolar disorder generally have trouble with relationships across the lifespan. Disrupted life domains in those with bipolar disorder include self-expression/self-improvement, family relationships, other social relationships, and work relations; these disruptions are observed even when the individuals with bipolar disorder are euthymic at the time of assessment (Robb et al., 1997). The social cost of bipolar disorder is thought to be considerable, but there are relatively few studies that address the social burden of this illness. Angst (1998) reported that the divorce rate is three- to six-folds higher in bipolar II versus controls. Family members and caregivers are reported to be considerably burdened, and their burden is frequently associated with the level of depression in the affected person (Ostacher et al., 2008). Thus, not surprisingly, individuals with bipolar disorder are more likely to be living alone, yet they are also noted to be more likely poor, less educated, or unemployed (or if employed more likely to have missed days), compared to those with major depression or no affective disorder (Shippee et al., 2011). The social limitations of this illness are compounded in part by the chaotic episodic nature of the disorder, but also based on the diluted capacity of affected individuals to establish healthy attachments that serve as templates for enduring relationships.

The causes of bipolar disorder are not yet fully elucidated, but it is widely accepted within the field that an interaction between biological susceptibility and environmental influences contribute to its etiology (McInnis et al., 2007). Environmental factors, including social context, may shape biological mechanisms that are genetically determined, or influence genetic function (expression) within the individual over the course of development. There is evidence of at least three associated genetic polymorphisms in those diagnosed with bipolar disorder (Clayton-Smith et al., 2010, Cohen-Woods et al., 2010, Cannon et al., 2011). The implications of these genetic variations, including abnormalities in cell structure, and dysregulation of cellular transmitters or receptors, are among the biological consequences related to these genetic polymorphisms that may explain some, but in reality very little, of the phenotypic aspects of bipolar disorder. The field that studies the non-genetic biology of gene expression is epigenetics, investigating how environment influences gene functionality. Epigenetics has been proposed responsible for some of the phenotypic variations in bipolar disorder course and illness severity that genetics or environmental effects alone are unlikely to explain (Petronis, 2003). Epigenetic studies suggest that early social context, most importantly early caregiving experiences, is a potentially crucial modifier of the associations between genetic vulnerability and development of mental health risks, and underscores the critical importance of secure child–parent attachment relationships as foundation for lifelong health (Miller et al., 1997, Francis et al., 1999). The stress that an infant experiences when exposed to inadequate parenting, leading to the establishment of an insecure attachment relationship pattern, has been found to hold meaningful biological and social implications for gene expression and is related to poor behavioral adaptation later in life (for a review, see Champagne and Curley (2005))

DNA methylation exemplifies an epigenetic mechanism that involves modulating gene expression as a consequence of early caregiving that may hinder the offspring׳s responsiveness (i.e. social responsivity) later in life. Most of this work has been demonstrated in animal studies. For example, Champagne et al. (2003) showed that rodent offspring reared in poor quality environments (i.e., low maternal licking/grooming) increased methylation of the glucocorticoid receptor (GR) gene, which is associated with decreased expression of this GR gene in the hippocampus area, leading to an increased and dysregulated stress response in the offspring. Conversely, being reared in high quality caregiving (i.e., high maternal licking/grooming) was associated with a decreased GR gene methylation, increased GR expression in the hippocampal area and decreased stress response. This research illustrates the effect of maternal care from one generation to next – maternal care given to offspring shapes offspring biological and behavioral outcomes. DNA methylation, along with other environmental factors, has similarly been proposed as epigenetic mechanisms that contribute to intergenerational influences in humans.

Current research and clinical indicators are consistent with a complex interplay between environmental and biological factors in the developmental trajectory of bipolar disorder (McGowan and Kato, 2008). It is postulated that environmental factors may evoke or protect against biological vulnerabilities in bipolar disorder, a combination of a genetic diathesis and stress (environment) (Post, 1992). The genetic diathesis–stress model may be helpful in understanding why close relationships may be so severely impacted by bipolar disorder; children of affected parents are not only genetically predisposed, but parental disorder may also increase the risk though an unpredictable caregiving environment, which in turn may interfere with the offspring׳s development of a secure attachment. Disrupted early caregiving may be an environmental risk that may potentiate genetic and epigenetic vulnerabilities. These factors may, in turn, create a deteriorating cycle – early close relationships may be affected by parental disorder, and if the children develop the disorder, their disorder may further interfere with and complicate their future relationships.

Few studies have focused on the role of interpersonal relationships on the presentation or course of bipolar disorder, or conversely, the impact of bipolar disorder on close relationships. There are three central domains of close relationships, including (a) early childhood child–parent attachment, (b) adult attachment (including romantic partnership), and (c) social support. Associations have been described between these domains and other psychiatric disorders including psychotic (Breier and Strauss, 1984) and depressive disorders (for a review see Wai Wan and Green (2009)), borderline personality disorder (for a review of the attachment literature, see Agrawal et al. (2004)), social anxiety disorder (Eng et al., 2001), and general psychiatric symptomatology (Hipwell et al., 2000, Shorey and Snyder, 2006).

Attachment Theory is a conceptual framework initially proposed by Bowlby (1969), a psychiatrist and ethologist who aimed to elucidate the evolutionary purpose underlying the formation of early social bonds between parents and offspring. Bowlby proposed that offspring are neurologically hardwired to form long-lasting emotional attachments to their caregivers for the purpose of proximity seeking in times of perceived danger, thus promoting survival of the species. Bowlby postulated this as a universal principle for all mammalian species. His follower, Mary Ainsworth, later specified that while attachments are universal for mammalian species, in humans, the quality of the attachment bond is unique for each dyad and is shaped by the cumulative experience of day-to-day interactions over the first year between the baby and the caregiver. She demonstrated that the quality of attachment can be measured in an experimental paradigm, the Strange Situation Paradigm (SSP) (Ainsworth and Wittig, 1969) The SSP classifies attachment styles as secure, insecure–avoidant, insecure–ambivalent, and disorganized through coding of behavioral indicators of approach and comfort seeking in a reunion episode following separation from the caregiver. The attachment style is thought to develop over the first year of life as consequence to the parents’ caregiving style. Later in life, during adolescence and adulthood, the measurement of attachment is through a person׳s narratives of childhood caregiving experiences during times that would elicit attachment behaviors, such as separations from caregivers, illness, or emotional and physical hurt (Obegi and Berant, 2010). Such narratives of attachment relevant memories are also called “internal working models of relationships,” and are thought of as memory templates that guide relational and social experiences across the lifespan (Main et al., 1985). Most interviews that tap into adult attachment working models tend to measure an adult׳s attachment to his or her family of origin instead of adult romantic relations (Jacobvitz et al., 2002). Finally, early attachment experiences can also be tapped into through retrospective self-report measures that ask an adult to report on their relationships with one or both parents when growing up (Parker et al., 1979). There are several self-report attachment measures available and validated (Armsden and Greenberg, 1987, Collins and Read, 1990, Bartholomew and Horowitz, 1991, Brennan et al., 1998). In summary, attachment is an established construct in developmental psychology known to contribute to a person׳s adjustment and developmental trajectory across the life span.

Most studies of social support seem to use semi-structured interviews or self report measures to elicit information about perceived social support and functional support, such as instrumental support, emotional support, or companionship. For example, the Interpersonal Support Evaluation List (Cohen and Wills, 1985) is a commonly used self-report scale that measures functional or perceived social support. The use of semi-structured interviews to elicit social support information is seemingly less common. One concern in measuring social support information, whether through interview or self-report, is the potential for reporting bias; in particular, the risk that current mood states may shape the respondent׳s evaluation of their social support. While reporting biases is a concern for any study with any population that solely uses self-report measures, this is a particular concern for studies involving psychiatric populations, given that one׳s perspective of social support or attachment could be affected by their current mood. In spite of this issue, however, self-report measures do give valuable insight into participants’ perceptions of their social relationships, and have been found to be valid and reliable.

Several prescient studies on bipolar disorder, summarized briefly in subsequent sections of this paper, hint at the important role that may be played by close relationships. The paucity of research on close attachment relationships and bipolar disorder represents a significant gap in the literature, in particular in view of the emerging interest in epigenetic influence on human development (Szyf, 2011).

The Social Convoy Model characterizes the role of close relationships across the lifespan (Kahn and Antonucci, 1980), and is useful for considering the importance of close relationships over the lifetime of individuals affected with bipolar disorder. This model provides a conceptual framework to integrate early attachment relationships with primary caregivers and social support provided by friends and romantic partners later in life, underscoring the lifelong importance of attachment and social support needs. According to this model, relationships across the lifespan are continuations of relationships that were formed in childhood based on formative experiences with early attachment caregivers. From this perspective, support provided by parents in early childhood plays a critical role as an infant begins life within a social convoy and his or her parents are typically the primary available social relationships. Sensitive support is likely to yield higher levels of attachment security in children. Secure children trust their caregivers, and are able to use them both as a “secure base” as they explore the world, and as a “safe haven” for comfort and regulation in times of distress (Bowlby, 1988). Early attachment security, in turn, provides children with subsequent increased sense of self-esteem and efficacy, and more trusting, well-regulated friendships with peers (Rosenblum et al., 2009). As the infant matures, the social convoy grows and changes as he or she forms close relationships with others, such as friends or romantic partners. As the child develops into an adult, he or she continues to exist within a social convoy. Paralleling secure attachment patterns in infancy and early childhood when interacting with caregivers, secure adult attachment reflects a balance between intimacy and independence, whereby the adult is able to establish and maintain closeness and intimacy, and yet does not unduly worry about acceptance by others. High levels of perceived social support provide the “secure base” and “safe haven” for an adult, allowing for optimal functioning. The link between attachment and social support is that perceptions of attachment figures are associated with perceptions of support from those same figures (Asendorpf and Wilpers, 2000). Research supports that for adults, the presence of at least one supportive close relationship is more important than who the specific relationship is with (e.g., parent, romantic partner etc.) (Levitt, 1991). Thus, the Social Convoy Model suggests that both social support and attachment theories reflect an underlying, evidence-based assumption that “crises+support/coping=increased wellbeing” (Antonucci and Akiyama, 1994, p. 40).

The Social Convoy Model facilitates understanding how individuals, regardless of age or partnership status, experience support from others, and the impact that this support has on their functioning and wellbeing. In the current review we use a Social Convoy framework to organize the extant literature on bipolar disorder and close relationships from a lifespan perspective, drawing from research on both attachment and social support.

Section snippets

Methods

This literature review reports on the results of a systematic review conducted with the PubMed, Medline, and PsycINFO search engines. We used the following key words: “bipolar” (used in all searches), “attachment,” “parenting”, “marriage”, “relationship”, and/or “social support.” Titles and abstracts of the articles listed through this search were individually reviewed to determine if they met the following additional methodological criteria:

  • 1.

    original empirical study published in a peer-reviewed

Results

In the following sections we provide a summary of the extant literature on close social relationships and bipolar disorder, reporting findings separately for bipolar disorder and child attachment, adult attachment, and social support.

Discussion

Social relationships and attachments are core to human existence and survival. From birth until death, humans exist within a social convoy that has implications for well-being. The relevance to bipolar disorder is established in the association of current metrics of recurrence and severity with evidence of poor social support and relationships patterns. This leads to the conclusion that social convoys play a significant role in the outcome of the illness; however, there are a number of

Conclusion

Social relationships are fundamental to human nature, and decades of research support that early caregiving experiences shape how individuals understand and process cognitions and emotions relevant for social interactions, which subsequently may impact the quality of all social relationships across the life span. Individuals with bipolar disorder have impairments in social relationships, as described in parenting contexts, romantic and family relationships and broader societal functioning.

Acknowledgments

This research was supported by the Heinz C. Prechter Bipolar Research Fund at the University of Michigan Depression Center.

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      Thus, despite the attempts of people who want to help, even those willing to do the best they can for those with BD, dealing with this chronic disorder is very difficult and can result in unpleasant emotions and maladaptive coping strategies among the relatives of the patients (Çuhadar et al., 2014). Corroborating our data, a recent review found that social relationships are significantly compromised in individuals with BD, and that lower levels of perceived SS were related to unfavorable outcomes in BD compared to patients with other mood disorders and to healthy controls (Greenberg et al., 2014). Considering the biopsychosocial dimensions in patients with BD, SS plays a significant role in their treatment, and researchers have showed that higher levels of perceived SS lead to a better prognosis in both longitudinal (O’Connell et al., 1985; Kulhara et al., 1999; Johnson et al., 2000; Cohen et al., 2004; Weinstock and Miller, 2010; Oddone et al., 2011) and cross-sectional studies (Romans and MacPherson, 1992; Beyer et al., 2003; Wilkins, 2004; Eidelman et al., 2012).

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