Cumulative Trauma’s Impact on Bipolar Disorder

Individuals diagnosed with bipolar disorder (BD) face trauma at significantly elevated rates compared to the general population. Research indicates that approximately 50% to 80% of these individuals have experienced at least one traumatic event throughout their lives (Assion et al., 2009; Maguire et al., 2008). Furthermore, studies have revealed that experiencing trauma correlates with more severe manifestations of the illness, such as earlier onset, heightened symptom severity, increased rates of comorbidity, and more frequent mood episodes (Hernandez et al., 2013).

While extensive reviews have focused on the relationship between childhood trauma and bipolar disorder, there exists a notable gap in research concerning trauma experienced in adulthood. Adult trauma, though less frequently examined, significantly impacts between 62% and 90% of individuals living with BD. Such traumatic experiences often arise from natural disasters, violent crimes, or assault (Maguire et al., 2008; Mowlds et al., 2010; Shannon et al., 2011).

Another vital aspect to consider is cumulative trauma, which refers to the build-up of multiple traumatic experiences over an individual’s lifetime. This accumulation can intensify psychological challenges, leading to severe depression and an increased risk for post-traumatic stress disorder (PTSD). Research shows that individuals diagnosed with bipolar-I disorder report an average of 3.7 traumatic incidents during their childhood (Kim et al. 2015), with a staggering 88% experiencing multiple traumatic events throughout their lives (O’Hare et al., 2013).

Much of the current research has concentrated on identifying childhood trauma without adequately addressing the frequency or extent of these traumatic experiences. To fill this research void, the paper by Rowe et al., (2023) systematically reviews previous studies to assess how frequently individuals with bipolar disorder encounter multiple traumas and the subsequent impact of these experiences on their overall mental health.

Systematic Review Methodology for Analyzing Trauma in Bipolar Disorder

Conducting a systematic review adhering to PRISMA guidelines was essential to examine the prevalence and outcomes associated with cumulative trauma in individuals diagnosed with bipolar disorder (BD). Researchers meticulously searched five databases—Embase, MEDLINE, PsycINFO, Web of Science, and PTSD Pubs—for relevant studies published from January 2010 through December 2022.

To qualify for inclusion in the review, studies had to adhere to specific criteria:

• Participants needed a formal diagnosis of BD according to DSM or ICD standards.
• Studies must utilize quantitative measures or screenings for various types of trauma, including childhood trauma, domestic violence, and PTSD.
• The extent of trauma experienced had to be documented, differentiating between single and multiple instances.
• Articles were required to present data on the prevalence of cumulative trauma and its related outcomes.
• The studies had to be empirical, comprising randomized trials, observational studies, or experimental designs.
• If BD was studied alongside other diagnoses, separate analyses for BD were imperative.

The authors also evaluated the Risk of Bias and conducted a Quality Appraisal using the Joanna Briggs Quality Appraisal Tools to ensure the integrity of the findings.

Key Findings on Cumulative Trauma in Bipolar Disorder

The review ultimately included 20 articles, collectively examining 9,304 participants with bipolar disorder (BD) from 13 different countries. The majority of these studies (95%) focused on adults aged between 31.5 and 68.5 years, while one study specifically targeted adolescents averaging 15.7 years. Two studies exclusively involved female participants, while 15 reported female representation ranging from 41% to 72%.

The prevalence of cumulative trauma identified within the studies varied significantly, ranging from 29% to 82%, and was associated with:

• Clinical characteristics of BD: Including prolonged mood episodes, an increased variety of treatments, more rapid cycling, postpartum depression, a higher number of lifetime depressive episodes, and decreased rates of euthymia.
• Psychosis: The findings regarding the relationship between cumulative trauma and psychosis were mixed; while two studies indicated a correlation, another two found no such evidence.
• Suicidal tendencies: Three studies established a link between cumulative trauma and suicidal behavior.
• Comorbid disorders: Three studies independently connected cumulative trauma with PTSD, substance use disorders, anxiety, and diminished psychosocial functionality.

Important Insights on Trauma’s Role in Bipolar Disorder

While research in this domain is still developing, this review reveals compelling connections between trauma and bipolar disorder (BD):

• The findings suggest that individuals who endure greater trauma may experience an earlier onset of BD, prolong mood episodes, and encounter more frequent mood fluctuations.
• Additionally, there appears to be a heightened risk of psychotic episodes and suicide attempts associated with increased trauma exposure.

These insights underscore the necessity for clinicians to thoroughly investigate their patients’ trauma backgrounds and integrate this understanding into treatment strategies.

Strengths and Limitations of the Current Study

This review provides an extensive and detailed examination of existing research concerning cumulative trauma and its effects on bipolar disorder (BD). By synthesizing findings from multiple studies, it offers a well-rounded perspective on the topic. One significant strength lies in the inclusion of a substantial sample size from various studies, which enhances the reliability and generalizability of the conclusions drawn, allowing for broader implications. Furthermore, the emphasis on cumulative trauma sheds light on how different traumatic experiences can significantly influence the onset and severity of BD.

Nonetheless, the review also uncovers notable limitations. A primary concern is the limited number of studies that specifically investigate cumulative trauma in adults. Only one study primarily focused on adult trauma but did not present prevalence statistics, leaving a considerable gap in our understanding. Moreover, many studies collected relevant data yet failed to analyze cumulative trauma accurately, complicating the ability to differentiate the impacts of single traumatic events from those of multiple occurrences. More comprehensive research is essential to clarify the definition of cumulative trauma, as establishing a consistent definition in future studies will facilitate a deeper understanding of its long-term effects.

Transforming Treatment Strategies: Implications for Mental Health Professionals

Several key implications for practice arise from this review. First, clinicians should prioritize the comprehensive gathering of trauma histories from their patients. A thorough understanding of the extent and nature of a patient’s traumatic experiences can significantly enhance treatment strategies and improve overall outcomes. Treatment plans ought to be individualized, specifically addressing the unique trauma experiences of each patient, particularly concerning how cumulative trauma may influence mood episodes, symptom severity, and the risks of psychosis and suicidality.

Considering the established link between cumulative trauma and the earlier onset of BD, implementing early intervention strategies for individuals with trauma history can be advantageous. Identifying at-risk individuals enables timely support and effective symptom management. Additionally, adopting a trauma-informed care model is essential. By fostering a safe environment, building trust, and empowering patients in their treatment choices, clinicians can significantly improve therapeutic relationships. For further insights on trauma-informed care, please refer to my previous blog.

Mental health professionals should also integrate assessments for suicidality and psychosis risk into their practice. Understanding the connections between cumulative trauma and these risks can facilitate timely interventions and comprehensive support for those affected.

Author’s Background and Interest Statement

The author of this blog operates within a Complex Depression, Anxiety and Trauma service, where they frequently collaborate with individuals diagnosed with Bipolar Disorder and a history of severe trauma. There are no conflicts of interest related to the research paper upon which this blog is based.

Essential References for Further Reading

Main Research Article

Rowe, A.-L., Perich, T., & Meade, T. (2024). Bipolar disorder and cumulative trauma: A systematic review of prevalence and illness outcomes. Journal of Clinical Psychology, 80, 692–713. https://doi.org/10.1002/jclp.23650

Additional References

Assion, H.‐J., Brune, N., Schmidt, N., Aubel, T., Edel, M.‐A., Basilowski, M., Juckel, G., & Frommberger, U. (2009). Trauma exposure and post‐traumatic stress disorder in bipolar disorder. Social Psychiatry and Psychiatric Epidemiology, 44(12), 1041–1049. https://doi.org/10.1007/s00127-009-0029-1

Dualibe, A. L., & Osório, F. L. (2017). Bipolar disorder and early emotional trauma: A critical literature review on indicators of prevalence rates and clinical outcomes. Harvard Review of Psychiatry, 25(5), 198–208. https://doi.org/10.1097/HRP.0000000000000154

Hernandez, J. M., Cordova, M. J., Ruzek, J., Reiser, R., Gwizdowski, I. S., Suppes, T., & Ostacher, M. J. (2013). Presentation and prevalence of PTSD in a bipolar disorder population: A STEP‐BD examination. Journal of Affective Disorders, 150(2), 450–455. https://doi.org/10.1016/j.jad.2013.04.038

Maguire, C., McCusker, C. G., Meenagh, C., Mulholland, C., & Shannon, C. (2008). Effects of trauma on bipolar disorder: The mediational role of interpersonal difficulties and alcohol dependence. Bipolar Disorders, 10(2), 293–302. https://doi.org/10.1111/j.1399-5618.2007.00504.x

Mowlds, W., Shannon, C., McCusker, C. G., Meenagh, C., Robinson, D., Wilson, A., & Mulholland, C. (2010). Autobiographical memory specificity, depression, and trauma in bipolar disorder. British Journal of Clinical Psychology, 49(2), 217–233. https://doi.org/10.1348/014466509X454868

Shannon, C., Maguire, C., Anderson, J., Meenagh, C., & Mulholland, C. (2011). Enquiring about traumatic experiences in bipolar disorder: A case note and self‐report comparison. Journal of Affective Disorders, 133(1–2), 352–355. https://doi.org/10.1016/j.jad.2011.04.022

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