Bipolar disorder was previously known as manic depression as it causes moods to shift between mania and depression. It may also be classified as a biological brain disorder causing severe fluctuations in mood, energy, thinking and behaviour. This disorder results in frequent anxiety and low frustration level in the young people (CABF 2007). Depression, in this situation, means a situation where you feel very low while mania would refer to a situation where you feel very high (NHS 2009). Sometimes, symptoms of mania and depression can also occur simultaneously (CABF 2007). These episodes can last for several weeks or longer. “The high and low phases of the illness are often so extreme that they interfere with everyday life” (NHS 2009).
In bipolar disorder, the depression phase often comes first. One can be diagnosed with clinical depression before having a manic episode. The manic episodes usually take place after some time, after which the diagnosis might change. These episodes of depression may lead to overwhelming feelings of worthlessness, which often lead to thoughts of suicide. The manic phase may make you feel very creative and view mania as a positive experience. This is the time when you may also have symptoms of psychosis. During this phase you may feel very happy and have lots of ambitions, plans and ideas. Lack of sleep and appetite are other also common characteristics of bipolar disorder (NHS 2009).
“People with bipolar disorder fluctuate between intense depression and mania, interspersed by periods of relative calm” (Macnair 2008).
The causes of bipolar disorder aren’t completely known, but are often hereditary. A cluster of factors both genetic and environmental, such as personal traumas or stress, can highly influence systems. The initial manic or depressive episodes of bipolar disorder usually take place early in the teenage years or early adulthood (Macnair 2008) At least half of all cases start before age 25 (Kessler et al., 2005). The symptoms of the disorder can be fairly subtle and may result in being overlooked or misdiagnosed. This could result in unnecessary suffering while on the other hand, with proper treatment and support; a fulfilling life can be lived (Macnair 2008).
In severe forms of mania, there are chances of a person becoming psychotic, with delusions. There is a conflict in perception and reality and there may be hallucinations and delusional beliefs about being persecuted. In some of the worst cases, people in mania become unintelligible and neglect themselves. The symptoms have varying patterns, frequencies and order. While in some case, where symptoms of mania are followed by symptoms of depression in a predictable pattern, some people have mixed symptoms – it’s possible to have many of the symptoms of mania and also suffer from severely depressive thoughts (Bhugra and Flick, 2005).
Although there’s no cure for bipolar disorder, many people find that an understanding of their illness and what triggers episodes can help them live a relatively normal life Macnair 2008). Patients could monitor their moods and thoughts and ask someone they trust to help them cope with the disorder. But, sometimes some people have extreme mood swings that can’t be managed by monitoring alone. There may be a need for antidepressants, antipsychotic medication, drug lithium, which seem to stabilise mood swings. High level of lithium in blood can be poisonous while too little will have no effect. So, its important to be seen regularly by the mental health team and have the blood levels checked (Smith et al., 2009).
John had a bipolar disorder with first episode happening when he was 19. At 28, John had evidently had manic episodes, as he had been known to contact his colleagues and clients at odd hours to discuss novel ideas. He kept enthusing about his designs being imaginative and original. At the workplace, clients and colleagues would complain about John’s unprofessional behaviour suggesting a lack of understanding on the part of his workplace. John’s denial of his illness further aggravated his situation. John had already quit two excellent jobs because of his condition.
John’s younger brother, Michael, managed to get John back to his consultant psychiatrist and pushed him to take his medicines regularly. With continuous support from his brother, John started responding well to the treatment. Although medication seemed to have positive effect on John, he would give up the medicines as soon he started feeling better. This resulted in relapses and repeated episodes. “And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense that they interfere with the patients ability to function” (Smith et al., 2009). John did not participate actively in social activities making it difficult for others to recognize his needs.
John could not focus on his work due to his medical condition being too unstable. John was not offered any job at the five places he had applied despite an impressive CV. This was due to the fact that John had mentioned his illness on all the forms raising doubts in John’s mind about disclosing his illness until it was specifically stressed upon.
Work labelling and stereotyping – Theory of stigma
Stigma is the difference between the virtual social identity and the real social identity. Stigma has three forms, which can be characterised as external, personal and tribal. The first form of stigma relates to external or overt deformations like scars, leprosy, physical disability and social disability. The second form relates to deviations in personal traits, including mental illness, drug addiction, alcoholism and criminal backgrounds. The third form, tribal stigmas, are imagined or real traits of ethnic groups, nationalities or religions that are deemed to constitute a deviation from what is perceived as to be the prevailing ethnicity, nationality or religion (Geoffman 1963).
eoffman (1963) also went on to describe 3 levels of deviance. He described them as primary, secondary and tertiary deviances. Primary deviance would refer to original violation/deviance/and societal reaction to this non-conformity to societal norms. The secondary deviance is the deviant’s reaction to the negative societal reaction and the tertiary deviance is the reaction of the stigmatised person to the stigma from other leads to master status. The secondary deviant attempts to re-label certain behaviours as normal rather than deviant. This is an attempt to create a label that overshadows all other characteristics.
The stigmatised person is seen as inferior by others and seen as having a perpetually flawed social identity and is thus discriminated. The stigmatised individual might also have additional imperfections imputed to them on the basis of the original stigmata thus creating stereotypes (Geoffman 1963).
Stigma can also be differentiated as felt and enacted. The felt stigma is the condition where one feels the shame of being identified with a discrediting condition and the fear of encountering enacted stigma. Enacted stigma is the actual episode of discrimination, both formal and informal against people with stigmata solely on the grounds of their having a stigmatising condition (Scambler 2004).
Scrambler (2004) through the Hidden Distress Model highlighted that people with a stigmata are fearful of experiencing enacted stigma and pursue an active policy of non-disclosure. The stigma has a far more disruptive effect on their lives as this also increases the stress of managing their disorder. The socio-cultural values can be viable in influencing the level of felt and enacted stigma.
According to Geoffmann’s (1963) classification of stigma, John fell in the second form due to hid bipolar disorder. As stated by Geoffmann (1963), John was ill treated and faced discrimination, which is quite evident from the behaviour of his clients and colleagues at work.
Sociology of Health and Illness
“The sociology of health and illness argues that socio-cultural factors influence people’s perceptions and experiences of health and illness, which cannot be presumed to be simply relations to physical bodily changes” (Nettleton 2006).
Defining Health and Disease
In the constitution of WHO established nearly half a century ago, health is defined as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity” (Saracci 1997). Temple et. al., in 2001 proposed a definition of disease though the approach did little to improve on previous attempts. They defined disease as a state that places individuals at increased risk of adverse consequences. Adopting this definition, every activity involving voluntary action carry a “risk of adverse consequences”.
The problem with the concept of health and disease is that it is associated with social concepts such as normality and abnormality, normality and abnormality being relative terms. “In common parlance, disease means a deviation from the established “norm”, consequently abnormal, with connotations of weirdness, strangeness, repulsiveness, viciousness, sickness, derangement, impairment, and disorder” (Landy 1977). Conditions may be characterised as normal or abnormal based on the ‘arbitrary diagnostic criteria’ as in most common diseases like diabetes, hypertension, etc. A condition is considered to be normal if it is prevalent amongst the population largely.
But this issue seems to be complicated by the ‘question of medicalization versus criminalization of abnormal social behaviour’ (Rosen 1968 and Foucalt 1972).
Often the clinicians’ diagnosis is influenced by social views on mental diseases. In cases where mental disorders are involved, judging a sick person is to be avoided at all costs. Instead, the situation and the effects of the disease should be judged (Scheff 1979). “The patient is worried with his own private and particular condition, while the doctor tries to make a diagnosis in the same way a zoologist or a botanist does with a specimen under the microscope: to weight individual variances against general signals and symptoms that agree with those of a recognized category of disease” (de Avila Pires 2008).
Failure to Recognize Mental States and Provide Required Support
Radley (1994) reported that it was very difficult to live with illness in today’s world where “health is more than meeting the demands of specific tasks or fulfilling particular duties.” Mental disorders may lead to the patient becoming socially isolated as was seen in John’s case.
Figure 1. The patient suffering from chronic illness faces various modes of adjustment. (Figure adapted from Radley and Green 1985, cited in Radley 1994)
According to the ‘modes of adjustment to the chronic illness’ put forward by Radley and Green in 1985 (cited in Radley 1994) John was in the phase of active denial. He resisted the illness symptoms and participated in the normal life, treating his illness as of little importance. Even his colleagues failed to recognize his condition and complained calling John’s behaviour unprofessional.
Factors that Pushed John to Seek Medical Help
Despite John’s being a talented architect, he had already quit two good jobs. The reasons attributed to this may be an atmosphere of discriminative behaviour in the workplace. John had developed a stage of Bipolar disorder where regular attacks of mania took place. He might also have developed psychosis suggested by the novel ideas and strange behaviour.
John’s brother, Michael actually got John to go back to the medicines. He tried to know what had happened and made sure John took his medicines regularly. Michael also managed to get John back to his consultant psychiatrist. So, it may be perceived that it was support of his brother, family support coupled with a discriminative behaviour at the workplace that pushed John to medications.
Disability and social inequality go hand in hand. The proof is well documented and evident in socio-economic circumstances (Nettleton 2006). Disabled people face many problems in their working life. In certain cases like accidents, a person may loose his value overnight while as, in case of recurrent illnesses, the patient goes through a gradual downfall Blaxter 1976). Lack of support from other people (family, friends, colleagues) often aggravates the medical condition of the patient (Radley 2004).
John’s medical condition became a cause of concern for his employers and clients alike. He had to quit two jobs to cope with the situation. Despite having experience and impressive CV, John was not able to get a job at any of the five places he had applied to. Evidently, his revealing his bipolar disorder would have put his future employers on alert and thus the discrimination. Instead, of understanding John’s condition and helping him overcome his disability he was rejected every time.
The World Health Organization recognizes primary health care to be effective in preventing illness. There has been a shift from primary health care to community care and this shift could be a result of three factors – therapeutic, economic and reforms in the medical model (Busfield 1986, cited in Nettleton 2006).
The entire concept of community care relies on the priority being given to the patient and not the disease. Social perceptions about the disability or the disabled, plays an important role in community-based rehabilitation. “The term community care is used both in a perspective sense to related to how people should meet the health and social needs of the dependent people and also a description of the set of services that are currently provided” (Stevenson 2008).
Many people often object to being referred to as disabled. It leads to the segregation and often discrimination (Blaxter 1976). As was seen in John’s case, despite being an impressive architect he was refused job at five places, which he thought was because of him disclosing his bipolar disorder.
The local authorities along with voluntary bodies are responsible for looking after the social needs of a disabled. This concept is based on the fact that community has to be involved in deciding the social needs of a disabled member and then making sure that those needs are taken care of in local conditions (Blaxter 1976).
Michael, John’s brother played a major role in John’s rehabilitation. He understood his needs and convinced him to see his doctor. As is the concept of community care, Michael gave priority to his brother and his needs rather than his disease. The same cannot be said about his colleagues or his clients. Instead of understanding John’s special needs, they deemed him unfit to work with them.
Cognitive Therapy of Depression
Beck et al., (1979) defined cognitive therapy as an “active, directive, time-limited, structured approach used to treat various mental disorders.” The rationale behind this definition is based on how a disabled person perceives and structures the world. His previous experiences and relation with other people affect his ‘cognitions’. “For example, if a person interprets all his experiences in terms of whether he is competent or adequate, his thinking might be dominated by the schema, ‘Unless I do everything perfectly, I am a failure.’ In such case he would react to all situations in terms of his competence even if those situations were not related to his competence in any way.
John’s getting rejected at five interviews, despite of an impressive CV, made him feel disadvantaged. He thought it was due to his mental disorder. These inequalities made him want to conceal his illness and not reveal it unless it was specifically asked about.
“People experience serious chronic illness in three ways: as an interruption of their lives, as an intrusive illness, and as immersion in illness. Rather, from their perspectives, illness disrupts their lives; it intrudes upon the day-frequently each day; it engulfs them” (Charmaz 1997).
John’s illness was an interruption in his life. He had to quit two jobs because of his illness and was further rejected a job at another five places due to his illness.
Parson’s Sick Role Theory
According to Parson (1951), sickness is not merely a ‘condition’ or a ‘state of fact’, it is rather a specifically patterned social role. The sick people have the right to be exempted from the normal social role. They cannot be blamed for their medical condition and have to be taken care of. On the other hand, they are expected to seek professional guidance and show a willingness to get well. The disabled people are either vulnerable and are often exploited by others or they may adopt deviance to evade responsibilities and can prove to be threat to the society.
John was vulnerable. He tried to get well and used to take medication as well, but his colleagues blamed him for his condition. They often complained against him. Moreover, after quitting his job, he could not get another job due to his disability.
According to Zola (1973, cited in Scambler 2008) most of the patients would over look their symptoms for quite some time before consulting a doctor. He also found that there had to be something else ‘a trigger’ apart from the symptoms to convince patients to seek medical intervention. The characterised five types of ‘triggers’ – First, “the occurrence of an interpersonal crisis (e.g., death in the family),” second, perceived interference with social or personal relations,” third, “sanctioning (pressure from others to consult),” fourth, perceived interference with vocalization or physical activity,” and fifth, ” a kind of temporalizing of symptomatology (the setting of deadline).” Moreover, patient’s personal and social circumstances also affect the patient’s decision to seek help.
Applying Zola’s theory to John’s case, one would realize that John did overlook his symptoms. He used to deny his illness and stop his medication as soon as he felt better. It was ‘sanctioning’ (pressure from his brother Michael) that acted as a trigger and convinced him to consult his psychiatrist and start his medication again.
A certain medical condition or disability refers to be presented with problems and face problems earning ones living or any other day to day activities. Many disabled people find it hard or lack the willingness to participate in the social activities. They isolate themselves from the society and in certain cases from family as well. But constant support from family and friends coupled with proper medication can help the patient recover and rise above his disability (Blaxter 1976).
Bipolar disorder being a chronic mental disorder has serious consequences on patients in particular and their families and societies in general. Effective treatment for bipolar disorder is available, but patients often hesitate to report their condition due to various social, economic and personal barriers. Patients often go into self-denial and try to remain away from social activities. There are two ways of caring for the bipolar disordered person; one, primary healthcare, that is consulting a general physician or a psychiatrist and second being community care. Concerted efforts on all levels (patient, family, community, healthcare provider and government) are required to improve the quality of care among the bipolar community (Bhugra and Flick, 2005).
Apart from the professional help, self-help can greatly improve the condition of a person with bipolar disorder. The patient should learn about his condition. It will help him understand his needs better as well as help him in recovery. They should try and avoid stress, participate in social activities and indulge in hobbies. The patient should keep a track of his mood swings and watch out for the symptoms that have deleterious effects on their mood. Doing so would help them prepare better for adverse conditions. Maintaining a healthy schedule (healthy food habits, exercising, and proper sleep) can greatly influence the moods of a patient (Smith et al., 2009).
Beck AT, Rush AJ, Shaw BF, and Emery G. 1979. Cognitive Therapy of Depression. New York, The Guilford Press
Bhugra D. and Flick GR. 2005. Pathways to care for patients with bipolar disorder. Bipolar Disorder 7; 236-245
Blaxter M, 1976. The meaning of disability. London. Heinemann.
CABF (Child and Adolescent Bipolar Foundation), Educating the Child with Bipolar Disorder, 2007
Charmaz K. 1997. Good Days, Bad Days-Illness and Time. USA, Rutgers University Press
de Avila-Pires FD. 2008. On the concept of disease. Revista de Historia & Humanidades Medicas, Vol. 4, No. 1
Foucault M. 1972. Histoire de la folie à l’âge classique, Paris, Gallimard
Goffman E. 1963. Stigma: Notes on the management of spoiled identities
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 62(6):593-602.)
Landy D. [Ed.], 1997. Culture, disease, and healing. Studies in medical anthropology. NewYork, Macmillan
Macnair T. 2008. Bipolar disorder. Available at: //www.bbc.co.uk/health/conditions/bipolar1.shtml[Accessed on 12/01/20101]
Nettleton S. 2006. The Sociology of Health and Illness; Cambridge, Polity Press
NHS 2009. Bipolar disorder. Available at: //www.nhs.uk/Conditions/Bipolar-disorder/Pages/Introduction.aspx [Accessed on 12/01/2010]
Parson T. 1951. The Social System. New York, Free Press.
Radley A. 1994. Making sense of illness. London, SAGE Publications
Rosen G. 1968 Madness in Society. Chapters in the historical sociology of mental illness, New York, Harper & Row
Saracci R.1997. The world health organisation needs to reconsider its definition of health BMJ1997;314:1409
Scambler G, 2004. A jigsaw model of health-related stigma, University College of London
Scambler G. [Ed.] 2008, Sociology as applied to medicine. (6th ed.) Saunders, Elsevier
Scheff T. 1979. Decision rules, types of error, and their consequences in medical diagnosis. In Albrecht G. and Higgins P. [Eds.] Health, Illness, and Medicine. A reader in medical sociology, Chicago, Rand McNally, pp. 313-326.
Smith M, Segal J, and Segal R. 2009. Understanding bipolar disorder. Available at: //www.helpguide.org/mental/bipolar_disorder_symptoms_treatment.htm [Accessed on 13/10/2010]
Temple LK, McLeod R, Gallinger S, and Wright J. 2001. “Defining disease in the genomics era”. Science, Vol. 293, No. 5531, New York, pp. 807-808