Torie B. Simmons
June 10, 2020
Bipolar disorder is a mental disorder that causes an individual to experience erratic shifts in mood, energy levels, and concentration, making it difficult to carry out day-to-day activities and affecting their quality of life and their ability to function psychosocially. (National Institute of Mental Health, n.d.)
According to The National Institute of Mental Health (NIMH) website, “There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels–”. Moods ranging from periods of extreme elation, irritability, energized behavior (known as manic episodes) to hopelessness, depression, and indifference. Manic episodes that are considerably mild or less severe are known as hypomanic episodes (National Institute of Mental Health, n.d.)
Trait impulsivity is a hallmark of bipolar disorder. Impulsivity is a multifaceted, complex, behavioral trait that affects an individual’s quality of life and their ability to function psychosocially (Muhtadie, Johnson, Carver, Gotlib, & Ketter, 2013). Better understanding of the nature of the relationship between bipolar disorder and its core characteristic of impulsivity could provide insight as to the course of illness and elucidate possible psychotherapeutic and/or pharmacological intervention. This research report will show trait impulsivity as central to the diminished quality of life experienced by bipolar individuals.
Keywords: bipolar, impulsivity, academic study, prefrontal cortex, reward sensitivity, criminal incarceration
Trait Impulsivity in Bipolar Disorder
Bipolar Disorder is a mood disorder characterized by mood instability and impulsivity. It has frequent comorbidity with substance abuse disorders and suicidality, often leading to criminal incarceration (Swan, Alan C, 2011). A manic phase in bipolar is characterized by heightened energy levels, restlessness, bouts of euphoria and/or agitation, heightened sense of self-worth and lack of need for sleep. A depressive state is the opposite side of the pole, characterized by loss of energy, depression, and low self-esteem that may lead to suicidal ideation (Diagnostic and Statistical Manual, 2013). Between bouts mania and depression is an euthymic state, characterized by remission from severe symptoms. Impulsivity is a core trait and diagnostic criterion for bipolar disorder and many other mental illnesses. The Diagnostics and Statistical Manual, 5th edition, (DSM-5) describes reckless behavior and indicates impulsivity as a diagnostic criterion. An examination of the complex relationship between impulsivity as a trait as it pertains to bipolar disorder may lead to a better understanding of optimal therapeutic and/or pharmacological intervention and improved quality of life among bipolar individuals.
Three studies were used to examine the dimensions of impulsivity in bipolar disorder in an attempt to get a well rounded perspective of the full range of implications: A profile approach to impulsivity in bipolar disorder: the key role of strong emotions, (Muhtadie, L., Johnson, S. L., Carver, C. S., Gotlib, I. H., & Ketter, T. A.,2013), Decision-making and Trait Impulsivity in Bipolar Disorder Are Associated with Reduced Prefrontal Regulation of Striatal Reward Valuation (Mason, L., O’Sullivan, N., Montaldi, D., Bentall, R., & El-Deredy, W., 2014), and Criminal Conviction, Impulsivity, and Course of Illness in Bipolar Disorder, (Swann, Alan C, Marijn Lijffijt, Scott D Lane, Kimberly L Kjome, Joel L Steinberg, and F Gerard Moeller). The studies that were examined used a combination of techniques to gather information, including structured clinical interviews to diagnose illness criteria, self-report questionnaire, and functional magnetic resonance imaging. All three studied were peer reviewed and noted any potential failures. All information gathered was analyzed and interpreted to configure results.
Individuals with bipolar disorder were found to exhibit multiple dimensions of impulsivity in all phases of the illness, however during manic phases of the illness they were particularly affected; moreover, positive emotions in particular correlated with high-risk behavior. The BAS (Fun-seeking) scale was the only instance that bipolar individuals were not found to be more impulsive than control subjects, which could also explain why impulsivity in this context generates negative outcomes. Findings suggest that bipolar individuals are particularly susceptible to making inappropriate, low-probability, high-risk, decisions during bouts of mania (Muhtadie, L. et al., 2013). Two studies emphasize the idea that bipolar individuals may be reward-sensitive and at particularly high risk for making hyper-hedonic choices regardless of the potential negative consequences, suggesting an impairment in response inhibition (Mason, L., 2014; Muhtadie, et al, 2013).
As previously mentioned, bipolar disorder is characterized by fluctuating mood and strong emotion. A study done in 2013 used several scales to measure different facets of impulsivity. The scales used were BS-11(Barrett Impulsiveness Scale, Version 11), BAS (Behavioral Activation System Fun-seeking), Positive Urgency, and Negative Urgency. BS-11 uses three higher-order subscales to measure impulsive behavior: Attention, Motor, and Non-Planning. The attention subscale refers to an individual’s ability to focus on a task, the motor subscale measures tendency to act without forethought, and finally, the non-planning aspect measures impulsivity pertaining to consideration of the future. The BAS is a self-report questionnaire using a Likert scale, designed to test an individual’s willingness to approach a goal-oriented outcome. The positive and negative urgency scales measure the likelihood of acting impulsively while experiencing strong negative or positive emotions, again using a Likert 1-4 scale. The study found that bipolar individuals are at high risk of acting impulsively when experiencing positive emotions. The results showed that bipolar individuals were more impulsive in every category aside from one: BAS (Fun-seeking). The study indicated that the type of emotion that bipolar individuals are most susceptible to exposes them to the most risk. Regulating and focusing on this dynamic between strong emotion and impulsivity is potentially a key component to psychosocial stability for bipolar individuals (Muhtadie, L., et al, 2013). Supporting the theory of hyper-sensitivity to reward, a study using fMRI provides information pertaining to a neural basis for the trait-like impulsivity. This study used functional magnetic resonance imaging to map brain activity while subjects performed tasks that highlight decisions associated with impulsivity. Study participants played roulette, showcasing the functional response to making decisions related to probability of reward. Appropriate and optimal decision making requires communication between frontostriatal areas of the brain (2011, as cited in Mason, L., et al, 2014 ). The study shows, long-term goals are associated with the dorsolateral prefrontal cortex and lower-order preference in ventral striatum; the ventromedial prefrontal cortex is responsible for creating a weighted valuation, and choices made are a result of this valuation. Results of this study indicate that impulsivity in bipolar is associated with bias towards the ventral striatum. Essentially, strongly desired outcomes are favored regardless of the optimal long-term choice (Mason, L., et al, 2014 ). As mentioned previously, BAS (fun-seeking) was the only impulsivity scale bipolar individuals in the former study were not found to be more impulsive on. As BAS relates to willingness to approach a goal-oriented outcome, these two ideas support each other. Interestingly, bipolar individuals show hyper activation of ventral striatum both during anticipation and experience of rewards. When anticipating outcomes individuals suffering from bipolar disorder showed a greater increase in left ventral striatal activation for high reward probability gambles in comparison to the control subjects. The study shows hyper-hedonic response toward reward and little response to losing, implying that they were highly sensitive to reward but not to loss (Mason, L., et al, 2014). This information supports the idea that bipolar individuals are most susceptible to the emotions that pose them the highest risk. It is strongly emphasized that mood regulation or affective instability alone was not the central aspect of poor quality of life associated with bipolar disorder, the impulsivity was based on poor goal regulation. A third study regarding “Criminal conviction, impulsivity, and course of illness in bipolar disorder”, used structured clinical interview techniques to examine the relationship between bipolar disorder, criminal conviction and mental illnesses that share impulsivity as a core trait. ASPD (Antisocial Personality Disorder), cluster B, and substance abuse disorders all share impulsivity as a core characteristic. This study aimed to examine the relationship between impulsivity associated with these disorders and the heightened risk for incarceration. The examination resulted in the assessment that criminal conviction (self-reported) was associated with antisocial personality disorder symptoms, manic predominance, and impulsivity associated with lack of response inhibition. Mania has been suggested in all studies to correlate with impulsivity, especially when associated with a negative outcome (Swann, Alan C., 2011). All sources researched contribute to the theory that bipolar individuals bias action valuation toward lower-order goal preference despite potential long-term negative consequences. It is also indicated that while impulsivity is multi-faceted, in relation to bipolar disorder, impulsive behavior is oriented around failure to evaluate risk, regulate and achieve goal-oriented outcomes (Muhtadie, et al, 2013; see also Mason, L., et al, 2014; Swann, Alan C., 2011).
In combination these three studies offer a multi-dimensional outlook on the implications of impulsivity as a trait in bipolar disorder and suggest that higher-order goal regulation and mood stabilization should be considered priority in psychotherapeutic or pharmacological intervention. More research could reduce suicidal ideation and improve quality of life in bipolar disorder.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: Dsm-5(5th ed.).
Swann, Alan C. (2011). Antisocial personality and bipolar disorder: Interactions in impulsivity and course of illness. Neuropsychiatry, 1(6), 599-610
Swann, Alan C, Marijn Lijffijt, Scott D Lane, Kimberly L Kjome, Joel L Steinberg, and F Gerard Moeller. “Criminal Conviction, Impulsivity, and Course of Illness in Bipolar Disorder.” Bipolar Disorders 13.2 (2011): 173-81. Web.
National Institute of Mental Health: Bipolar Disorder. (n.d.). Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Muhtadie, L., Johnson, S. L., Carver, C. S., Gotlib, I. H., & Ketter, T. A. (2013). A profile approach to impulsivity in bipolar disorder: the key role of strong emotions. Acta Psychiatrica Scandinavica, 129(2), 100–108. doi: 10.1111/acps.12136
Mason, L., O’Sullivan, N., Montaldi, D., Bentall, R., & El-Deredy, W. (2014). Decision-making and trait impulsivity in bipolar disorder are associated with reduced prefrontal regulation of striatal reward valuation. Brain, 137(8), 2346-2355.