Manic and Bipolar Syndromes

  • Heinz BoekerEmail author
  • Simone Grimm
  • Peter Hartwich
  • Georg Northoff


Patients with bipolar disorders show numerous neuropsychological impairments, not only during depressive and manic episodes but also after remission of symptoms. These dysfunctions are associated with structural and functional changes in cortical and limbic brain regions and have a profound impact on patients’ psychosocial functioning. This chapter gives an overview on relevant neuroscientific and neuropsychological findings in bipolar disorders. Furthermore, the personality structure and the interpersonal relationships of bipolar patients are taken into account.

In a neuropsychodynamic perspective, the hypernomic und ambiguity-intolerant behaviour of bipolar patients may be looked upon as an attempt to cope with an impending threat of a collapsing self-worth regulation and the shame which results from the experience of mania. In case of an instability of the self-image, a narcissistic slight or a disappointment (with an impairment of the ideal self) may induce a regression to the precursor stages of the ideal self (regressive activation of the grandiose self) or an actualization of other intrapsychic elements of the self-worth regulation and their precursors (e.g. complete submission to the claims of a rigid, rigorous superego). This may be interpreted as an attempt to cope with the narcissistic dysbalance and the danger of a depressive reaction.

The conceptualization of manic symptoms as mood modulators has important implications for the understanding and treatment of mania. The confrontation with the “temptation of mania” is of fundamental importance in the treatment of mania. The effectiveness of the drug treatment and the compliance of the patients depend on their attitude to mania essentially. In this context mania may not only be comprehended as the experience of a fatal disorder but also as a condition which is intended and desired. The neuropsychodynamic view of manic symptoms as mood modulators constitutes an important basis for the dialogue with the patients and provides them with a better understanding of their painful renunciation of the manic sense of euphoria.


Bipolar disorders Mania Neuropsychological impairments Self-worth regulation Psychosocial functioning 


  1. Angst J. Zur Ätiologie und Nosologie endogener depressiver Psychosen. Berlin: Springer; 1966.CrossRefGoogle Scholar
  2. Arts B, et al. Meta-analyses of cognitive functioning in euthymic bipolar patients and their first-degree relatives. Psychol Med. 2009;39(3):525.CrossRefGoogle Scholar
  3. Bearden CE, et al. The impact of neurocognitive impairment on occupational recovery of clinically stable patients with bipolar disorder: a prospective study. Bipolar Disord. 2011;13(4):323–33.CrossRefGoogle Scholar
  4. Beblo T, et al. Specifying the neuropsychology of affective disorders: clinical, demographic and neurobiological factors. Neuropsychol Rev. 2011;21(4):337–59.CrossRefGoogle Scholar
  5. Benedetti FP, et al. Disruption of white matter integrity in bipolar depression as a possible structural marker of illness. Biol Psychiatry. 2011;69(4):309–17.CrossRefGoogle Scholar
  6. Bleuler E. Die Probleme der Schizoidie und der Syntonie. Zeitschrift für die gesamte Neurologie und Psychiatrie. 1922;78(1):373–99.CrossRefGoogle Scholar
  7. Blumberg HP, et al. A functional magnetic resonance imaging study of bipolar disorder: state- and trait-related dysfunction in ventral prefrontal cortices. Arch Gen Psychiatry. 2003;60(6):601–9.CrossRefGoogle Scholar
  8. Böker H. Selbstbild und Objektbeziehungen bei Depressionen: Untersuchungen mit der Repertory Grid-Technik und dem Giessen-Test an 139 PatientInnen mit depressiven Erkrankungen. Monographien aus dem Gesamtgebiete der Psychiatrie. Darmstadt: Steinkopff-Springer; 1999.CrossRefGoogle Scholar
  9. Böker H. Psychotherapie bei bipolaren affektiven Störungen. In: Böker H, Hell D, editors. Therapie der affektiven Störungen. Psychosoziale und neurobiologische Perspektiven. Stuttgart: Schattauer; 2002. p. 230–45.Google Scholar
  10. Bonnin CM, et al. Clinical and neurocognitive predictors of functional outcome in bipolar euthymic patients: a long-term, follow-up study. J Affect Disord. 2010;121(1–2):156–60.CrossRefGoogle Scholar
  11. Bora E, et al. Cognitive endophenotypes of bipolar disorder: a meta-analysis of neuropsychological deficits in euthymic patients and their first-degree relatives. J Affect Disord. 2009;113(1–2):1–20.CrossRefGoogle Scholar
  12. Carlson GA, Bromert EJ, Sievers S. Phenomenology and outcome of subjects with early- and adult-onset psychotic mania. Am J Psychiatry. 2000;127:213–9.CrossRefGoogle Scholar
  13. Chen CH, et al. A quantitative meta-analysis of fMRI studies in bipolar disorder. Bipolar Disord. 2011;13(1):1–15.CrossRefGoogle Scholar
  14. Christensen H, et al. A quantitative review of cognitive deficits in depression and Alzheimer-type dementia. J Int Neuropsychol Soc. 1997;3(6):631–51.PubMedGoogle Scholar
  15. Clark L, Goodwin GM. State- and trait-related deficits in sustained attention in bipolar disorder. Eur Arch Psychiatry Clin Neurosci. 2004;254(2):61–8.CrossRefGoogle Scholar
  16. Cotter D, et al. The density and spatial distribution of GABAergic neurons, labelled using calcium binding proteins, in the anterior cingulate cortex in major depressive disorder, bipolar disorder, and schizophrenia. Biol Psychiatry. 2002;51(5):377–86.CrossRefGoogle Scholar
  17. Cousins DA, et al. Lithium, gray matter, and magnetic resonance imaging signal. Biol Psychiatry. 2013;73(7):652–7.CrossRefGoogle Scholar
  18. Denicoff KD, Leverich GS, Nolen WA, et al. Validation of the prospective NIMH-life chart-method (NIMH-LCM-p) for longitudinal assessment of bipolar illness. Psychol Med. 2000;30:1391–7.CrossRefGoogle Scholar
  19. Elia C. Der psychodynamische Zugang zum manischen Patienten. In: Benedetti C, et al., editors. Psychosentherapie. Stuttgart: Hippokrates; 1983. p. 263–317.Google Scholar
  20. Gabbard GO. Psychodynamic psychiatry in clinical practice. 5th ed. Washington DC: Amer Psychiatric Publ; 2014.Google Scholar
  21. Ghaemi SN, Stoll SL, Pope HG. Lack of insight in bipolar disorder: the acute manic episode. J Nerv Ment Dis. 1995;183:464–7.CrossRefGoogle Scholar
  22. Goodwin FK, Jamison KR. Manic-depressive illness. Oxford, NY: Oxford University Press; 1990.Google Scholar
  23. van Gorp WG, et al. Cognitive impairment in euthymic bipolar patients with and without prior alcohol dependence - a preliminary study. Arch Gen Psychiatry. 1998;55(1):41–6.CrossRefGoogle Scholar
  24. Gualtieri CT, Morgan DW. The frequency of cognitive impairment in patients with anxiety, depression, and bipolar disorder: an unaccounted source of variance in clinical trials. J Clin Psychiatry. 2008;69(7):1122–30.CrossRefGoogle Scholar
  25. Hartwich P, Pfeffer F Die bipolare Psychodynamik in der Gruppenpsychotherapie. Pilotstudie zur Wirksamkeit. Vortrag auf dem Kongress “Bipolare Störungen” am 21.09.2007 an der Ruhruniversität Bochum, published in Hartwich P, Grube M (2015) Psychotherapie bei Psychosen, Kap Größenwahn und Scham. Heidelberg: Springer; 2007. p. 117–26.Google Scholar
  26. Himmighoffen H. Selbstwertproblematik und psychosoziale Bewältigungsstrategien bei PatientInnen mit bipolaren affektiven Psychosen. In: Böker H, editor. Depression, Manie und schizoaffektive Psychosen. Psychodynamische Theorien, einzelfallorientierte Forschung und Psychotherapie. 3rd ed. Giessen: Psychosozial-Verlag; 2000. p. 227–43.Google Scholar
  27. Hollon SD, Ponniah K. A review of empirically supported psychological therapies for mood disorders in adults. Depress Anxiety. 2010;27:891–932.CrossRefGoogle Scholar
  28. Hsiao YL, et al. Neuropsychological functions in patients with bipolar I and bipolar II disorder. Bipolar Disord. 2009;11(5):547–54.CrossRefGoogle Scholar
  29. Jamison KR. An unquiet mind. New York: Vintage Books; 1995.Google Scholar
  30. Karnath HO, Sturm W. Störungen von Planungs- und Kontrollfunktionen. Klinische Neuropsychologie. H. W. P. K. Stuttgart: Thieme; 2002.Google Scholar
  31. Kempton MJ, et al. Meta-analysis, database, and meta-regression of 98 structural imaging studies in bipolar disorder. Arch Gen Psychiatry. 2008;65(9):1017–32.CrossRefGoogle Scholar
  32. Kipp J, Stolzenburg H-J. Stimmungsmodulation und die Psychodynamik der Manie. Psyche – Zeitschrift für Psychoanalyse. 2000;54:544–66.Google Scholar
  33. Kraus A. Neuere psychopathologische Konzepte zur Persönlichkeit manisch-depressiver. In: Mundt C, Fiedler P, Lang H, Kraus A, editors. Depressionskonzepte heute. Berlin: Springer; 1991.Google Scholar
  34. Kretschmer E. Körperbau und Charakter. 26th edition, 1921. Berlin, Heidelberg, New York; 1977.Google Scholar
  35. Kröber H-L. Akute Krisen bei Manien. Nervenheilkunde. 1992;11:1–3.Google Scholar
  36. Kröber H-L. Bipolare Patienten im Intervall: Persönlichkeitsstörungen und Persönlichkeitswandel. Nervernarzt. 1993;64:318–23.Google Scholar
  37. Kurtz MM, Gerraty RT. A meta-analytic investigation of neurocognitive deficits in bipolar illness: profile and effects of clinical state. Neuropsychology. 2009;23(5):551–62.CrossRefGoogle Scholar
  38. Leonhard K. Die präpsychotische Temperament bei den monopolaren und bipolaren phasischen Psychosen. Psychiatr Neurol. 1963;146:105–15.CrossRefGoogle Scholar
  39. Lezak M. Neuropsychological assessment. Oxford, NY: Oxford University Press; 1995.Google Scholar
  40. Lim CS, et al. Longitudinal neuroimaging and neuropsychological changes in bipolar disorder patients: review of the evidence. Neurosci Biobehav Rev. 2013;37(3):418–35.CrossRefGoogle Scholar
  41. Liu SK, et al. Deficits in sustained attention in schizophrenia and affective disorders: stable versus state-dependent markers. Am J Psychiatry. 2002;159(6):975–82.CrossRefGoogle Scholar
  42. Lyoo IK, et al. Lithium-induced gray matter volume increase as a neural correlate of treatment response in bipolar disorder: a longitudinal brain imaging study. Neuropsychopharmacology. 2010;35(8):1743–50.CrossRefGoogle Scholar
  43. Mann-Wrobel M, et al. Meta-analysis of neuropsychological functioning in euthymic bipolar disorder: an update and investigation of moderator variables. Bipolar Disord. 2011;13(4):334–42.CrossRefGoogle Scholar
  44. Martinez-Aran A, et al. Functional outcome in bipolar disorder: the role of clinical and cognitive factors. Bipolar Disord. 2007;9(1–2):103–13.CrossRefGoogle Scholar
  45. Matussek P, Luks O, Seibt G. Partner relationships of depressives. Psychopathology. 1986;19:143–56.CrossRefGoogle Scholar
  46. Mentzos S. Neurotische Konfliktverarbeitung. Frankfurt/M: Fischer; 1984.Google Scholar
  47. Mentzos S. Depression und Manie; Psychodynamik und Psychotherapie affektiver Störungen. Göttingen: Vandenhoeck und Ruprecht; 1995.Google Scholar
  48. Mentzos S. Lehrbuch der Psychodynamik. Die Funktion der Dysfunktionalität psychischer Störungen. Göttingen: Vandenhoeck & Ruprecht; 2009.Google Scholar
  49. Möller HJ. Zur Bedeutung und methodischen Problematik der psychiatrischen Persönlichkeitsforschung: Der “Typus melancholicus” und andere Konzepte zur prämorbiden Persönlichkeit von Patienten mit affektiven Psychosen. In: Marneros A, Phillip M, editors. Persönlichkeit und psychische Erkrankung. Berlin: Springer; 1992. p. 45–65.CrossRefGoogle Scholar
  50. Möller HJ, von Zerssen D. Prämorbide Persönlichkeit von Patienten mit affektiven Psychosen. In: Kiska KP, Lauter H, Meyer J-E, Müller C, Strungren E, editors. Psychiatrie der Gegenwart Band V. Berlin: Springer; 1987. p. 165–79.Google Scholar
  51. Ongur D, et al. Glial reduction in the subgenual prefrontal cortex in mood disorders. Proc Natl Acad Sci U S A. 1998;95(22):13290–5.CrossRefGoogle Scholar
  52. Osher Y, et al. Computerized testing of neurocognitive function in euthymic bipolar patients compared to those with mild cognitive impairment and cognitively healthy controls. Psychother Psychosom. 2011;80(5):298–303.CrossRefGoogle Scholar
  53. Paykel ES. Handbook of affective disorders. New York: Guilford; 1995.Google Scholar
  54. Perris C. A study of bipolar (manic-depressive) and unipolar recurrent depressive psychosis. Acta Psychiat Scand Suppl. 1966;194:1–89.Google Scholar
  55. Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: challenges and future directions. Lancet. 2013;381(9878):1663–71.CrossRefGoogle Scholar
  56. Phillips ML, et al. A neural model of voluntary and automatic emotion regulation: implications for understanding the pathophysiology and neurodevelopment of bipolar disorder. Mol Psychiatry. 2008;13(9):833–57.CrossRefGoogle Scholar
  57. Rajkowska G, et al. Reductions in neuronal and glial density characterize the dorsolateral prefrontal cortex in bipolar disorder. Biol Psychiatry. 2001;49(9):741–52.CrossRefGoogle Scholar
  58. Robinson LJ, et al. A meta-analysis of cognitive deficits in euthymic patients with bipolar disorder. J Affect Disord. 2006;93(1–3):105–15.CrossRefGoogle Scholar
  59. Sartre JP. Being and nothingness. An essay on phemonemological ontology. Translated by Barnes H E Philosophical Library, Inc, New York, L’é’tre et le néant. Essai d’ontologie phénoménologique (1943). Paris: Librairie Gallimard; 1956.Google Scholar
  60. Schwarz F. Psychodynamische Psychotherapie bei bipolaren Störungen. Z Psychiatr Psychol Psychother. 2014;62(4):273–81.Google Scholar
  61. Simpson SG, Jamison KR. The risk of suicide in patients with bipolar disorders. J Clin Psychiatry. 1999;60(Suppl 2):53–6.PubMedGoogle Scholar
  62. Söldner M, Matussek P. Kindheitspersönlichkeit und Kindheitserlebnisse bei Depressiven. In: Matussek P, editor. Beiträge zur Psychodynamik endogener Psychosen. Berlin, Heidelberg, New York: Springer; 1990. p. 134–62.CrossRefGoogle Scholar
  63. Strakowski SM, et al. The functional neuroanatomy of bipolar disorder: a consensus model. Bipolar Disord. 2012;14(4):313–25.CrossRefGoogle Scholar
  64. Tellenbach H. Melancholie. Zur Problemgeschichte, Typologie, Pathogenese und Klinik. Berlin, Göttingen, Heidelberg: Springer; 1961.Google Scholar
  65. Torres IJ, et al. Neuropsychological functioning in euthymic bipolar disorder: a meta-analysis. Acta Psychiatr Scand Suppl. 2007;434:17–26.CrossRefGoogle Scholar
  66. Townsend J, Altshuler LL. Emotion processing and regulation in bipolar disorder: a review. Bipolar Disord. 2012;14(4):326–39.CrossRefGoogle Scholar
  67. Versace A, et al. Abnormal left and right amygdala-orbitofrontal cortical functional connectivity to emotional faces: state versus trait vulnerability markers of depression in bipolar disorder. Biol Psychiatry. 2010;67(5):422–31.CrossRefGoogle Scholar
  68. Willi J. Die zweier Beziehung. Spannungsursachen – Störungsmuster – Klärungsprozesse – Lösungsmodelle. Hamburg: Rowohlt; 1975.Google Scholar
  69. Wirz-Justice A, Quinto C, Cajochen C, Werth E, Hock C. A rapid-cycling bipolar patient treated with long nights, bed rest, and light. Biol Psychiatry. 1999;45(8):1075–7.CrossRefGoogle Scholar
  70. Zerssen von D. Premorbid personality and affective psychoses. In: Burrows GD, editor. Handbook of studies on depression. Amsterdam: Excerpta Medica; 1977. p. 79–103.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Heinz Boeker
    • 1
    Email author
  • Simone Grimm
    • 2
  • Peter Hartwich
    • 3
  • Georg Northoff
    • 4
  1. 1.Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric University Hospital Zurich, University of ZurichZurichSwitzerland
  2. 2.Charité, Universitätsmedizin Berlin, Klinik für Psychiatrie und PsychotherapieBerlinGermany
  3. 3.Department of Psychiatry, Psychotherapy, PsychosomaticsGeneral Hospital of Frankfurt am Main, Teaching Hospital University FrankfurtFrankfurtGermany
  4. 4.Mind, Brain Imaging, and Neuroethics, Institute of Mental Health ResearchUniversity of OttawaOttawaCanada

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