# Motivation and emotion/Book/2019/Mania and motivation

* Multimedia presentation (3 min)

## Overview

Everyone experiences ups and downs with both motivation and emotion, and most people are able to manage these fluctuations reasonably well. For an example of a normal fluctuation in mood consider yourself and how motivated you feel after a good night sleep versus very little sleep.
However, problems begin to arise when your heightened or low mood interrupts normal functioning, has negative impacts on your life and causes distress (American Psychological Association, 2013). This is a sign of a mental disorder or mental illness that requires treatment.
Throughout this chapter you will find out what mania is, how it effects[grammar?] motivation and what psychological treatments are available, as well as the difficulties with treatment options.
* Focus questions:
* 1. What are the specific types of motivation associated with mania?
* 2. How does these differences of motivation affect an individual?
* 3. How will this impact psychological treatment?
* 4. What implications are there for individuals suffering from mania?

## What is mania?

The word mania comes from ancient Greek and referred to madness or an irrational obsession (Sani, Kotzalidis & Girardi, 2017). A manic episode is characterised by elevated, expansive or irritable mood and increased goal-directed activity and energy (American Psychological Association, 2013). A manic episode can also cause an inflated self-esteem, decreased need for sleep, distractibility, excessive involvement in activities with highly likely painful consequence (American Psychological Association, 2013). It is important to note that mania can present differently for different individuals,[grammar?] for some it is a heightened state which helps productivity while others experience of mania may hinder their functioning and have negative social and interpersonal consequences.

### Who experiences mania?

Mania is a common symptom of bipolar disorder but can also occur in Disruptive Mood Dysregulation disorder and as a result of substance use (American Psychological Association, 2013). Substances reported to induce or heighten manic symptoms are often from the stimulant family of drugs including caffeine, amphetamine and cocaine (Alcohol and Drug Foundation, 2019; Lake, Tenglin, Chernow & Holloway, 1983). There is also suggestion by research that Cannabis (Marijuana) may also induce manic symptoms in some individuals as well as some prescription medication (Iskandar, Griffeth & Sharma, 2011; Thomas & Sharma, 1996).

### Why does mania occur?

Bipolar I has a strong genetic risk factor,[grammar?] this suggests there are biological factors that can increase the likelihood of developing Bipolar and experiencing manic episodes (American Psychological Association, 2013). There are also links between mania and abnormal neurochemistry in regards to the reward centre of the brain (Tal, Haggai, Godfrey & Talma, 2014). It is difficult however, to determine what causes the disease and what are factors that are caused by the disease (Martinowich, Schlosser & Manji, 2009). A manic episode can also be induced by stress and life events in susceptible individuals, indicating environmental factors also play a role in the onset of mania (Gonen, Sharon, Pearlson & Hendler, 2014).

### What are the common treatments for mania?

Many people may consider "why is mania a bad thing?" or "why does it need treatment?". When considering the effects of mania one must realise that being in a manic state is not sustainable and can have negative consequences. Mania also brings with it the risk of suicidal behaviour, substance use problems, relationship problems and fatigue (Bassett, 2010). Treatment for individuals experiencing mania is important and can be treated using prescription medication or psychological treatments (Levenson, Nusslock & Frank, 2013).
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### Quiz 1: Mania
## Mania: Theoretical basis

A theoretical basis is important in understanding both the cause of mania and the associated changes or differences in motivation. Several theories have been proposed to explain the onset of mania and the subsequent effects on motivation.

### Reinforcement sensitivity theory: extrinsic motivation

The reinforcement sensitivity theory depicts that motivation occurs as a result of the degree of sensitivity an individual has towards rewards and punishment and this is the main source of goal-directed behaviour (Carver & Johnson, 2010; Johnson, Sellbom & Phillips, 2013; Tal, Haggai, Godfrey & Talma, 2014). There are many other theories that reflect the same premise such as goal dysregulation theory and BAS dysregulation theory (Carver & Johnson, 2008; Tal, Haggai, Godfrey & Talma, 2014). All these theories suggest that mania is the result of an overly sensitive reward system. It is suggested that this would show in a tendency towards increased reactivity to rewards.
People with bipolar experiencing mania show a heightened sensitivity to rewards, while people diagnosed with depression are more likely to be sensitive to punishment (Finucane, Jordan & Meyer, 2012). Therefore, people suffering from mania are more likely to be effected[grammar?] by external rewards (Arjmand et al., 2017; Ruiter & Johnson, 2015). A reason for this is differences in activity and chemistry in the brain; it is suggested that hypo-activity of the left dorsal prefrontal cortex and orbitofrontal cortex induce mania in contrast lower functional connectivity on the right dorsolateral prefrontal cortex and orbitofrontal cortex may initiate depression (Arjmand et al., 2017). But what causes shifting between both manic and depressed states in patients with bipolar disorder?

### Manic defence hypothesis: Implicit motivation

This hypothesis put forward by Neale (1988) suggests that mania results from a defence mechanism that counteracts low feelings associated with depression (Neale, 1988 as cited Finucane, Jordan & Meyer, 2012). This helps better explain the shifting in moods related to bipolar disorder. This theory would support findings that mania has minimal link to external stimuli and more to do with the implicit variables. Finucane and colleagues found an significant correlation between mania and implicit hope for success (2012). This interesting finding may support the idea that a rebuttal from the self occurs to counteract negative emotions. However, they did not find that implicit fear of failure predicted mania which according to the manic defence hypothesis would be the initiator in the sequence of a increase in implicit hope for success (Finucane, Jordan & Meyer, 2012).
Low self-esteem is often a symptom of depression, however, findings suggest that individuals in remission from bipolar are also likely to have low self-esteem (Winters & Neale, 1985). Interestingly, the low self esteem in Bipolar individuals is more likely to be concealed by self-deception and defensiveness (Winters & Neale, 1985). This idea that negative feelings are avoided by the individual supports the idea that mania is a protective response to very negative feelings. Other findings also suggest that mania is linked with negative cognitive styles and this plays a role in the onset of mania (Carver & Johnson, 2010; Scott, Stanton, Garland & Ferrier, 2000).

### Quiz 2: Motivation
## Mania and motivation

[Provide more detail]

### Intrinsic motivation

Intrinsic motivation is motivation to initiate and continue a behaviour due to personal value such as enjoyment and interest (Carver & Johnson, 2008). Generally speaking research has found no significant correlation between intrinsic motivation and mania. However, the underlying low-self esteem and negative cognition may play a role in the non-appearance of intrinsic motivation. Some research actually indicates that people who experience mania have lower intrinsic motivation (Carver & Johnson, 2008; Scott, Stanton, Garland & Ferrier, 2000)

### Extrinsic motivation

Extrinsic motivation arises from external stimuli such as incentives and potential gains (Ruiter & Johnson, 2015). This type of motivation is considerable higher in individuals that[grammar?] experience mania as outlined by the reinforcement sensitivity theory (Gonen, Sharon, Pearlson & Hendler, 2014; Ruiter & Johnson, 2015). In particular, individuals experiencing bipolar disorder are significantly more likely to be impacted by social expectations and [missing something?]

### Social dominance motivation

Social dominance motivation is a branch of extrinsic motivation that reflects the need for power and achievement (Johnson, Leedon & Muhtadie, 2000). This kind of motivation is similar to extrinsic motivation in that it is driven by the perception of opportunities and threats in the environment (Johnson, Leedon & Muhtadie, 2000; Ruiter & Johnson, 2015). This also supports the reinforcement sensitivity hypothesis.

### Approach Motivation

Approach motivation relates to seeking out novel stimuli or experiences (Meyer, Beevers, Johnson & Simmons, 2007). People who have experienced mania are significantly more likely to show higher approach motivation (Fulford, Eisner & Johnson, 2015; Meyer, Beevers, Johnson & Simmons, 2007; Tal, Haggai, Godfrey & Talma, 2014). Approach motivation can be good in some situations, for example if you require to undertake a new task that you have no previous experience with. On the other hand, approach motivation can also be not so good; think about the consequences of a person trying to approach a novel animal as seen in Figure 3. Approach motivation is related to the reinforcement sensitivity theory or BAS dysregulation theory. There are 2 systems in the brain that regulate seeking out or moving away from stimuli. The first is the Behavioral Approach System (BAS), and the second is the Behavioral Inhibition System (BIS) (Carver & Johnson, 2008). The BAS dysregulation theory posits that high sensitivity to rewards or over-activation of the BAS underlies mania (Tal, Haggai, Godfrey & Talma, 2014).
Approach motivation is also in part affected by cognition; a person is much more likely to approach if they believe the benefits out-weight the cost. It has been shown that people experiencing mania are more likely to base chance decisions on irrelevant previous experiences and therefore are more likely to take risks (Stern & Berrenberg, 1979).

## Difficulties with psychological treatment

Psychological treatment or psychotherapy is a method of treatment that focuses on changing some dysfunctional aspect about the person (Hollon & Ponniah, 2010). Drug treatment options often come with undesirable side effects that cause the individual to abandon treatment or may not work at all for an individuals (Hollon & Ponniah, 2010). Also drug treatment works by reducing symptoms of the disorder but do not typically treat the cause of a mental disorder (Hollon & Ponniah, 2010). What this means is that often psychological treatment is preferred or used in accompany with medication.
Treatment for bipolar disorder is necessary as it can be a life threatening disorder with individuals diagnosed with bipolar disorder 15 times more likely to take their own lives when compared to the average person (American Psychological Association, 2013). Psychological treatment helps the individual to build strategies to prevent relapse, reduce symptoms and live a happier healthier life (Hollon & Ponniah, 2010). So you may be wondering how can we effectively treat those diagnosed? And what are the difficulties with administering treatment?

### Efficacy

A meta-analysis undertaken by Oud and colleagues (2016) indicated that psychological treatments produces low or very low correlation in regards to improvement in manic symptoms. Within the study they looked at family-focused therapy, cognitive behavioural therapy (CBT), interpersonal and social rhythm therapy (IPSRT), integrated group therapy (IGT), psycho-education and collaborative care. CBT, family-focused therapy and IPSRT are the most commonly employed psychological treatments for Bipolar disorder (David, Lynn & Montgomery, 2017). There are many difficulties within using psychological treatment and these must be addressed in order to better cater to individuals living with bipolar disorder.

#### Cognitive behavioural therapy (CBT)

CBT is based on the Diathesis-Stress model which explains a mental disorder as a combination of genetic vulnerability and stressful life experiences (Burns & Machin, 2013; David, Lynn & Montgomery, 2017). There is evidence to support the idea that life events are strongly associated with negative well-being (Burns & Machin, 2013; Carver & Johnson, 2009; Hollon & Ponniah, 2010). CBT is a widely used tool for many mental illnesses and is very well regarded for the treatment of depression (David, Lynn & Montgomery, 2017). Findings indicate that CBT is effective in treating depressive episodes in individuals diagnosed with bipolar, however, effectiveness is limited when the individual is experiencing manic episodes (David, Lynn & Montgomery, 2017).

#### Interpersonal and social rhythm therapy (ISRT)

IPSRT is based on the understanding that illness is in part due to stressful interpersonal experiences (David, Lynn & Montgomery, 2017). This is very similar to the understanding that is the basis of CBT however focuses more on integrating the individual into social activities including work (Perich, Manicavasagar, Mitchell, Ball & Hadzi-Pavlovic, 2013). It is important for the individual to be able to manage outside events so as not to be susceptible to relapse of manic episode. This treatment avenue fits well within the manic defence hypothesis as it proposed that negative feelings initiate a manic episode. ISRT has been shown to reduce symptom severity and increasing social functioning (David, Lynn & Montgomery, 2018).

#### Mindfulness based cognitive therapy

MBCT is a course of psychological treatment that helps the individual to be more self-aware and able to manage their emotions without getting overwhelmed or caught up in them (David, Lynn & Montgomery, 2018; Perich et al., 2013). This therapy has been shown to reduce the number of manic episodes but only with consistent treatment, as once treatment has ceased relapse is just as likely (Perich et al., 2013).

#### Family focused therapy

Family focused therapy is aimed at creating protective support both in the social and family context by the means of psychoeducation, communication skills and problem solving skills training (David, Lynn & Montgomery, 2018). Family and close social circles are an invaluable source of support for an individual experiencing Bipolar disorder (Bassett, 2010). It is associated with less frequent and and shorter duration of recurrent episodes (David, Lynn & Montgomery, 2018; Perich et al., 2013).
Table 1.
Summary of the different types of therapy and the outcomes from treatment.
| Type of therapy | Main effects of treatment |
| CBT | Effective in treating depressive episodes. |
| ISRT | Reduce symptom severity and increase social functioning. |
| Mindfulness based cognitive therapy | Reduce number of manic episodes for the time treatment is continued. |
| Family focused therapy | Less frequent and shorter episodes. |

### Personal factors

A second source of difficulty in psychological treatment for mania is personal and social beliefs. For example a collection of research indicates that 27% of creative individuals have symptoms of mania or a diagnosis of bipolar disorder compared to 5.2% of non-creative individuals (Johnson et al., 2011). Bipolar disorder (both I and II combined) has a prevalence rate of 1.8% globally,[grammar?] this indicates that the results of the study mentioned may have an exaggerated number of cases of bipolar in the sample (American Psychological Association, 2013). However, a significant difference between highly creative individuals and non-creative individuals in regards to mania remains present. Individuals who experienced heightened creativity while experiencing mania may channel this to produce more content for their own personal and professional gains. This may lead to the perception that their experiences with mania do not require treatment or that they do not want to be treated.
In addition, individuals experiencing mania have a higher drive and high goal setting which may appear effective during the episode of mania to both the individual and those around them but can also be linked to low feelings from non-achievement and have been connected with substance misuse (Fulford, Eisner & Johnson, 2015).

### Quiz 3: Treatment
## Conclusion

There are many things that are not currently known about mania and how motivation is impacted by the disorder. Much research suggests that mania is caused by over-sensitivity to external rewards, which produced higher approach motivation and extrinsic motivation. Similarly, social dominance motivation appears to be heightened in individuals who experience mania.
Another suggestion which has a solid experimental basis is the idea that individuals experience mania as a self-defence mechanism against negative thoughts and feelings. This suggests that a person experiences mania as a self initiated course of action to protect against negative feelings.
Undertaking treatment and continuing treatment can be difficult for many individuals for a number of reasons. Often drug treatment has a number of undesirable side effects that dissuade the individual from continuing medication. There are also difficulties for individuals experiencing mania to seek treatment due to personal beliefs and perception of society at large. Psychological treatment for Bipolar disorder is not as well researched or proven efficacious when compared to depression. However, there are a range of different therapy's[grammar?] that all have positive outcomes for the individual and help reduce symptoms, enable coping and give support.