Understanding high functioning in people with a diagnosis of bipolar disorder

Background: Although there is evidence to suggest that some people with BD may be functioning successfully, previous literature has predominantly focused on impairment. Consequently, there is limited understanding of 'high functioning' in BD, including related factors and how it is experienced by those with a diagnosis. The Cognitive Behavioural (CBT) model offers a holistic approach to understanding onset and maintenance of BD, and consideration of the same range of factors may be able to increase understanding of how people function alongside their experiences. Aims: This PhD project aimed to increase understanding about people who are functioning at a high level alongside their BD diagnosis. Additionally, it aimed to identify predictors of functional level over time, and whether level of functioning influences attendance at group treatment programmes. Finally, this PhD aimed to recognise the subjective experiences of high functioning in people with a diagnosis who perceived themselves to be functioning at a high level. Methods:. A systematic review explored the BD literature for commonly used measured of social and occupational functioning. Pooled descriptive statistics from studies using these measures revealed population norms for functioning in BD. Multilevel linear modelling analyses were used to determine clinical and demographic predictors of functioning over time in a large BD sample, originally collected for a randomised controlled trial of psychoeducation versus peer support. A linear regression and moderation analysis, conducted using the same dataset, investigated whether functioning predicted level of attendance at psychoeducation or peer support groups in people with BD, and whether functioning level moderated the relationship between clinical and/or demographic variables and attendance at the groups. Finally, 20 self-defined high functioning individuals with a BD diagnosis were recruited for a qualitative interview study. Interviews and subsequent thematic analyses focused on participants' experiences of functioning alongside their mood experiences, including how they defined their high functioning as well what they felt had contributed to it. Results: Pooled analyses of descriptive data extracted from studies using commonly used measures of functioning revealed that around 16% of individuals with a BD diagnosis can be expected to function at a high level. Multilevel linear modelling analyses revealed that increases in level of depression resulted in functional decline, however increases in mania only resulted in decline following an increase above the overall sample mean. People with a higher or postgraduate level of education were more likely to have higher and stable functioning over time, compared to those with lower education levels who were seen to decline. Those who were in employment were also seen to retain their functioning over time compared to those who were retired or unemployed. Linear regression analyses found that level of functioning did not predict level of attendance at psychoeducation or peer support groups, however it moderated the relationship between employment status and group attendance. Those who were low functioning were equally likely to attend the groups if they were employed or unemployed, however those with higher functioning were more likely to attend if they were unemployed. Finally, four key themes were identified through a thematic analysis which revealed that the way in which people defined their high functioning and pre-existing foundations for high functioning influenced strategies used by participants to support their functioning, and over time all of these developed and changed as a result of their experiences. Conclusions: There is a wide variability in the level of functioning of people with a diagnosis of BD, with a significant proportion functioning at a high level. In line with the CBT model, a variety of factors are related to functional level and the experience of 'high functioning' in BD. Mood changes and sociodemographic factors such as education level and employment status influence functional trajectory over time. However, functioning moderates the relationship between employment status and level of attendance at group treatment. This thesis contributes to current understanding of high functioning in people with a diagnosis of BD, and how this is experienced by those who are living the life they want to live alongside their mood experiences. Further research and clinical implications are discussed.