Motivation and emotion/Book/2015/Bipolar disorder and motivation in the work place

Overview
This chapter focuses on the effects of bipolar disorder and motivation in the work place. A brief overview of both bipolar disorder and motivation is provided. There will be an in depth discussion on the symptom clusters of bipolar disorder in accordance to the Diagnostic Statistical Manual of Mental Disorders (2013) which will be followed by a discussion of how each set of symptoms affect motivation. The theories of motivation which will be covered include intrinsic and extrinsic theories of motivation. To emphasize the importance of this subject this chapter will take a look at the prevalence of mood disorders in Australia and will consider the impact this statistic have in the workplace. A brief look at treatment options for individuals experiencing bipolar disorder will lead to workplace interventions for healthier workplaces for people with mental illness. A concluding summary will outline the important research findings which have been discussed and referenced in the body of this chapter.

What is Bipolar Disorder?


The word bipolar can be broken down into two sections: “bi” meaning two and “polar” meaning opposing poles. From this definition we begin to develop a general understanding of what this disorder is about. Patients experience two categories of symptoms, depression or mania/hypomania in a cyclical pattern. There are also two types of bipolar: Bipolar I which has more severe symptoms and bipolar II with less sever symptoms (American Psychiatric Association, 2013; Murray & Johnson, 2010). Simply put, individuals with bipolar disorder experience extreme mood swings across long (6 months- 1 year) or short (3 weeks or more) periods of time, which negatively impact on the individuals daily functioning (Blackdoginstitute.org.au, 2015).

Bipolar disorder has also been referred to as bipolar affective disorder and manic depressive illness, however the latest diagnostic manual published by the American Psychiatric Association (2013) has narrowed the terminology to Bipolar Disorder. Therefore, to maintain a clarity, this is the terminology which will be used in this text.

What is motivation?
Motivation is the ability to begin or continue with a goal or activity. The word motivation comes from the Latin term “movere”. When we break down the word movere (movement) we can deduct two key components: energy and direction (Higgins & Sorrentino, 1986). These two components also make up the key aspects of motivation: What fuels our motivation? And what is our motivation aimed towards?

While there are many theories of motivation, this chapter will be focusing on extrinsic and intrinsic theories, and neurological theories of motivation in relation to bipolar disorder symptoms. A brief explanation of the relevant theories will be given and then an in depth analysis will follow in each symptom cluster.

Individuals become intrinsically motivated when they encounter a subject or activity which they find themselves taking part off with no obvious goal, the interest is not due to an external aim or need but due to unexplained personal desire. Anecdotally, people whom have hobbies sometimes have trouble explaining why they like knitting, reading, watching movies or playing video games. This type of motivation has been proven to produce better learning and achievement outcomes (Ryan & Deci, 2000).

Extrinsic motivation is, in contrast, interests which are driven by a goal or outcome. This means that there does not have to be an inherent interest in the subject or activity but there is an interest in what it produces. An example of this could be working: Mr. X could be uninterested in his cleaning job, but he is interested in the money which it provides him with. While extrinsic motivation is more common and often found in everyday activities, it does not produce the same quality of results as intrinsic motivation (Ryan & Deci, 2000).

Bipolar and motivation
This section outlines symptoms that are usually found in patients with bipolar disorder through the Diagnostic Statistical Manual 5 and will discuss how each area of this disorder affects motivation. However it should be noted that people are unique and experience things differently. If, while reading the following information, you believe that you maybe affected by this disorder it is strongly encouraged that you seek help. A self-test can be found on the Black Dog Institute website, which can be used as a good starting tool for yourself and your health provider. However the results should be viewed with discretion and always with the aid of a specialist.

DSM-5


This section is where bipolar I and II differ, for a diagnosis of Bipolar Disorder I at least one manic episode must have occurred (exhibiting at least three symptoms). Patients' with bipolar II do not experience mania. The symptoms often include (American Psychiatric Association, 2013):
 * Increased self-esteem or grandiose ideals (must be notably different from normal and consistent from over several weeks)


 * Decreased need for sleep (individual often feels as if sleep is a waste of time)
 * Abnormally talkative (again must be different from a person's average behaviour)
 * Flight of ideas or the experience of racing thoughts (this often appears as incoherent and rapid speech)
 * Easily distracted (while an individual is likely to be more productive during a manic episode they often commit to too many tasks dividing their attention between them often spending short bursts of time on each one)
 * More goal directed planning (linked to grandiose ideals, goal directed planning often takes form of unrealistic large goals)
 * Risk taking (often through monetary, sexual and physically dangerous actions)

Motivation discussion
As noted above, patients with bipolar disorder during a manic stage often set hard to achieve goals. This movements can be described as periods of high motivation. However they often cause damage and distress to the individual who is experiencing these symptoms (Carver & Johnson, 2008). Johnson, Fulford & Carver (2012) have suggested that this occur due to high extrinsic motivation during manic periods. Experiencing an increase in a neural chemical which increases mood (serotonin) encourages the individual to feel more positive emotions than usual and therefore leads them to believe they can achieve hard to obtain goals in short periods of time. A patient with bipolar in a manic period is more likely to become extrinsically motivated, this produces problems when the patient sets unrealistic goals (such as writing a novel on the weekend) and then fails to meet the objectives they have set for themselves. This sensitivity to extrinsic motivation during manic periods can often be destructive, specially in a work place setting. Promising to deliver large amounts of work or high quality assignments in unreasonably periods of time can have damaging effects on an individuals credibility. The failure to achieve set goals can also lead to depressive episodes (Carver & Johnson, 2008; Johnson, Fulford & Carver, 2012).

Another theory behind the influence of extrinsic motivation in manic patients emphasizes the importance of grandiose self beliefs. To uphold this inflated self-esteem, individuals set unrealistic goals which they believe are unobtainable to the general population. However, to prove to themselves and others that they truly are unique, they must achieve this goals. Therefore high levels of "extrinsic hope of success" and "implicit fear of failure" motivate the individuals actions (Finucane, Jordan & Meyer, 2013). This need to uphold a grandiose image can lead to risk taking, which could endangering a patient's job or career depending on the severity of their actions.

DSM-5
Hypomania is a less severe form of mania experienced by individuals with bipolar II, therefore the symptom list is the same, however they usually do not impair daily functioning. The patient is likely to display:
 * Increased energy levels (which is often seen as increased productivity in the work place or at home)
 * Positive mood (a generally stable more positive outlook)
 * While the symptoms are often mild, the changes are usually observable by close relatives, friends or coworkers

It should be noted that for a diagnosis of Bipolar I only one manic episode must have been experienced, however the patient is also likely to have periods of hypomania (American Psychiatric Association, 2013).

Motivation discussion
Unlike mania, hypomania is more likely to evoke intrinsic motivation (Dodd, Mansell, Morrison & Tai, 2011). The theory behind this difference extends from the level of positive mood that the patient experiences, as mentioned above, intrinsic motivation is characterised by unexplained interest towards a topic or activity. Everyone has woken up one morning and felt particularly cheerful and energized, during this day we are more likely to do things we do not normally do or that we have not done for a long time. We do not stop to question why we are doing all this things but instead we continue on enjoying our activities. If we expand this day into a week or more we can get a small glimpse into what someone experiencing hypomania feels. Therefore it is easy to understand why people experiencing hypomania are more likely to be intrinsically motivated, as the feeling of increased positive outlook and energy (in a small amount) could lead to taking part in activities which have no obvious goal or achievement outcome (Dodd, Mansell, Morrison & Tai, 2011).

This phenomenon has been noticed in the work place and has had positive implications for the individual in the position, however hypomanic episodes are relatively short and could emphasize the drop in productivity during a depressive cycle. While the above illustration of hypomania may sound pleasant, it should not be forgotten that it is part of a greatly debilitating mental illness when left untreated (Dodd, Mansell, Morrison & Tai, 2011).

DMS-5


For a diagnosis of Bipolar Disorder I & II reoccurring periods of depression should be observer in the patient with at least four symptoms, in Bipolar I the symptoms are generally more severe. In accordance the Diagnostic and statistical manual of mental disorders (American Psychiatric Association, 2013) the symptoms for depression include:
 * Noticeable increase of negative mood (such as prolonged periods of sadness with or without an external reason)
 * Decrease interests in normally pleasurable activities (eg. hobbies, sports, social events)
 * Unusual decreased or increased appetite (without the intent to diet or purposefully gaining weight)
 * Insomnia or hypersomnia consistently (not due to external sources such as work commitments)
 * Psychomotor agitation (often seen as pacing, pulling at fingers or clothes, tapping, etc.)
 * Loss of energy (not as a result of exhausting activities but as a stable constant feeling)
 * Diminished concentration (can impact the completion of simple daily tasks in severe episodes)
 * Excessive feelings of worthlessness or guilt (without triggering negative event)
 * Recurrent thoughts of death or suicide

Motivation discussion
While it would seem to be a fair assumption to think that someone who suffers from depression (specially severe depression) has little or no motivation, but this is wrong. However, the subject and direction of the motivation often makes the depression worse. Theories of implicit and explicit motivation have aimed to explain how they may play a role in depression (Carver & Johnson, 2008). Someone who {{missing{{ experiencing low mood affect might feel implicit motivation to take part in tasks that alienates them from co-workers. The low mood simply changes the target behaviours, a patient who is experiencing depression might also be extrinsically motivated to avoid going to work in order to reduce the chance of an unpleasant situation (Carver & Johnson, 2008). Therefore depression (low mood affect) can cause the explicit need for avoiding anxiety provoking stimuli and an implicit need for isolation. This directions of motivation can cause serious issues in the workplace; as isolation and reduced productivity sends a negative message to an employer whom might create an uncomfortable workplace due to the behaviour and therefore the patient could continue to withdraw. In extremes this situations{{grammar}} can cause job losses and/or significant distress for the patient.

Prevalence
Bipolar disorder has been consistently found to be in the top 10 most incapacitating illnesses universally. This disorder can lead to higher divorce rates, higher rates, alcohol and substance abuse and fluctuating work performance (American Psychiatric Association, 2013; Nusslock et al., 2012).

The Australian Bureau of Statistics (2015) has recently reported rates of mental and behavioural disorders in the general population, with a staggering 3.0 million (13.6%) people being affected. The measure of mood disorders included Depression, Dysthymia and Bipolar Disorder (I and II), which constituted 6% of the 13.6% of general mental and behavioural disorders. The affected individuals were between the ages of 16-85 and had symptoms in the 12 months prior to the survey. Females were more likely to reported mood disorders than males both in the 12 months prior to the survey (7% compared to 5%) and in their life span (18% compared to 12%) (Abs.gov.au, 2015).

The high number of people affected by this disorder and the issues it can create in workplace situations makes this topic an important issue for both employees and employers. This next section will address treatment options and workplace interventions for people experiencing bipolar disorder.

Causes & motivation
Serotonin is a neurotransmitter (chemical) in the brain which helps regulate emotions.

Many, if not all mental illnesses have no single causal factor. In this section this chapter will attempt to introduce some of the key theories, which when integrated, produce a balanced theory of possible causes of bipolar disorder.

The diathesis-stress model poses that one causal factor of bipolar disorder could be stressful life experiences, particularly during crucial periods of development. Stressful experiences during early life can lead to poor cognitive development leaving an individual unable to handle future life events in a healthy well adjusted manner (Grunebaum et al., 2006).

There is also evidence to suggest that biological vulnerability, such as genetic predisposition could also play a part in the development of bipolar disorder. Patient’s family history of mental health has had positive results in predicting future possibilities of developing a mental health disorder (Johnson & Roberts, 1995). Another important aspect of the biological perspective outlines the abnormal serotonin balance in the brain of patients’ whom suffer from bipolar. Serotonin is a neural transmitter which aids the regulation of mood, however there are many chemicals in the human brain which interact in a very complex manner. Therefore the abnormality of one neural transmitter in bipolar patient’s brain only alerts us of what could be a warning sign for another more complex abnormalities (Benedetti et al., 2015; Nusslock et al., 2012).

Environmental factors can also play a huge roll in the development of mental illness. Beck’s cognitive model suggests that psychological vulnerabilities can arise through family stressors, poor upbringing or sustained abuse. This model is different from the diathesis-stress model because it does not require a single traumatic event or stressful life incident, but instead it suggests that the negative experience could be less severe in nature but prolonged. These stressors could result in cognitive impairments leading to the development of bipolar disorder (Mass, Wolf & Lincoln, 2012).

Biological based treatments

 * Pharmacological therapy (mood stabilizers): medication such as mood stabilizers have proven to be effective in treating symptoms of bipolar as this disorder has been proven to have a strong biological component. However medication can often have side effects which can interfere with an individuals ability to complete their job requirements (Pompili et al., 2014)..
 * Electroconvulsive therapy (ECT): this type of therapy is usually used when the patient has tried every other type of therapy and has had little to no long lasting results. While this therapy has evolved a lot through medical advancements, it still carries a lot of stigma. However positive results have been found in cases of patients whom have had little success with other treatments . This form of therapy can be expensive and time off work is required to undergo the procedure, depending on an individuals financial situation this may or may not be a viable option (Nordenskjöld, 2015).

Psychological treatments

 * Cognitive Behavioural Therapy (CBT): this therapy combines behaviouralist approaches and psychotherapy to change maladaptive cognitions (thoughts and thought patterns) and behaviours (actions) to replace them with healthier adaptive strategies (Hofmann, Asnaani, Vonk, Sawyer & Fang, 2012). CBT can be expensive, however in Australia it is subsidized by the government (Health.act.gov.au, 2015). Appointments can be made to suit the patient's schedule, so it has minimal impact on their work commitments. As the therapy progresses and if the patient responds well to treatment, this therapy can improve performance in the workplace through increased general mental health and stability.
 * Psychosocial interventions: aim to educate both the patient and family or caregivers (if the patient is underage) and other participating parties (work supervisor) about bipolar disorder and the course of treatment the patient will be taking. Providing psychoeducation to both the patient and family/caregivers improves the chances that the treatment will be adhered to, as well as increasing better psychological support from the support group. It has also been found that families/caregivers whom do not have adequate information about the patient's needs, are more likely to put psychological stress on the patient. Including the patient's employer in the psychological intervention can be beneficial for a number of reasons: if the patient has a relapse into a depressive or manic episode, an employer would be among one of the people to notice a change in performance. This can enable to employer to contact family members to ensure that the patient is getting the treatment they need and also safe guard against premature dismissal of the individual. (Muralidharan, Kotwicki, Cowperthwait & Craighead, 2014).

Combined therapeutic techniques
While combined therapeutic techniques have not been proven to be more effective than either biological or psychological treatments alone, research has proven that using both types of therapy reduces the number of relapses a patient has. It has been suggested that biological therapies aim to treat the immediate symptoms and while psychological therapies provide the life skills necessary to decrease relapse and increase quality of life (McIntyre, 2015). Including Psychoeducation in the work place aids to reduce stigma surrounding mental illness and alerting employers of mental illness can reduce employment issues for the patient (Cakir, Bensusan, Akca, & Yazici, 2009).

Interventions for mental illness in the work place
LaMontagne, Milner, Tchernitskaia & Noblet (2015) devised an intervention with beyondblue workplace training for staff and managers. This training consisted of psychoeducation, leadership sensitivity workshop, individual management coaching sessions, and diminishing job stress and team building activities for all staff. While there was a statistically significant change in survey results between the control group (which did not receive the intervention) and the experimental group (which did receive the intervention), the authors did not find a significant difference of social perception of working conditions and psychoeducation before and after the intervention. This means that while people did not perceive themselves to be receiving better mental health support from their workplace, individuals did respond that the level of care had improved after the intervention.

A closer look at the needs of the individuals would perhaps give a more clear understanding of what the employees need from the employers. However, the training and psychoeducation provided to the employers in LaMontagne, Milner, Tchernitskaia & Noblet (2015) study is a huge step to improving relationships and understanding about mental illness in the workplace.

Tremblay (2011) conducted a study looking at the needs of the individual in the workplace. The participants were outpatients diagnosed with bipolar I or II disorder. As part of the study participants were required to complete a questionnaire addressing what aspects of their workplace could be improved to enhance their occupational performance. The author found that the following workplace characteristics were the most valued by the participants: flexible hours (which included ability to work from home and leave of absence), independence (allowing for: regular breaks, work space barriers, self management of goal-setting, creativity), and supervisor readiness to adjust to needed changes (such as avoidance of machinery paced dependent jobs). While a follow up and implementation of the variables found was not conducted, this research uncovered the changes which are necessary to improve workplace mental health of people suffering from bipolar disorder. These changes can be easily implemented and at little cost of the employer, which could reduce workdays missed due to mental illness which benefits both the employer and the employee.

When both types of interventions are utilised, it provides employers with the skills necessary to address issues which may need to be resolved, and it gives employees with bipolar disorder a voice to be able to accommodated their needs and be a more healthy and productive member in their workplace. Increasing intrinsic and extrinsic motivation in the workplace and to maintain good levels of mental health can only be achieved by providing support for the people who need it most. Heads up is an Australian organisation which has brought together other organisation which have been raising awareness about mental illness in the workplace. It provides information and intervention strategies for creating a better healthier workplace based on empirical research, the information is presented in easy to understand and easily applicable ways. Its aim is to reduce mental illness stigma by acquiring recognition that mental illness is just as important and can be as debilitating as physical illness.

Conclusion
This chapter we have looked very closely at the symptoms of bipolar disorder and their impacts on intrinsic and extrinsic motivation in the workplace as well as some neurological influences. Due to the large spectrum of symptoms of this disorder and its complex causes of development, there will never be one theory of motivation or workplace intervention which will account for individual differences. However intrinsic and extrinsic theories are flexible theories of motivation which have helped to explain how a lot of the symptoms interact and affect the workplace. The research discussed above has allowed us to develop a greater understanding of motivation, treatment options and workplace interventions for people living with bipolar disorder. However, bipolar disorder continues to be an issue, and while the treatments and interventions have been successful in reaching out to a lot of people they have not been able to adjust to everyone's needs. More research is required to find other alternatives and better treatment strategies for those patients whom have not found success with existing interventions. Specifically research surround extrinsic and intrinsic theories of motivation and bipolar disorder in the workplace could greatly aid daily functioning and support for individuals suffering from this condition.