Bipolar Disorder: Identity, Social Support, Religiosity and Spirituality. Can Religiosity/Spirituality be a Mood Balancing Factor? An Italian Case Report

The US National Institute of Mental Health has classified bipolar disorder (BD) as a severe mental illness (SMI) negatively impacting psychological/physical and social/occupational health; it is comprised of a complex group of severe and chronic mental health conditions that cause extreme mood swings. Both the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) and the 11th version of the International Classification of Diseases (ICD-11) divide bipolar disorders into BD-I, BD-II and Cyclothymic, with diagnosis for BD-I being a past or present manic or mixed episode, for BD-II at least one hypomanic episode and one major depressive episode, and for Cyclothymic disorder, “at least 2 years (for children, a full year) of both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression” (APA, 2013).

BD usually requires life-long treatment, with lithium being generally considered to give optimum results as a mood-stabilizing agent (Buoli et al., 2020; Volkmann et al., 2020) although it has been suggested that there is a certain variability in the response (Papiol et al., 2022). As this illness often leads to functional impairment, long-term therapeutic interventions would appear to be essential to avoid psychotic symptoms, thus preventing relapses and preserving cognition (Bonnín et al., 2019). Although pharmacotherapeutic treatments are fundamental for effective recovery, an integrated approach including psychosocial interventions, individual psychoeducation, increasing physical exercise, compliance enhancement strategies and public health initiatives (McIntyre et al., 2020) is recommended.

Social support, defined by James House (1981) as “emotional concern, instrumental aid, information, and appraisal,” can influence clinical outcomes in people diagnosed with a bipolar disorder and appears to affect a broad range of biological and psychological processes. Many instruments have been developed over the years to measure social support: in particular, Cohen and Hoberman’s Interpersonal Support Evaluation List (ISEL) created in 1983 and validated in Italian in 2011 (Moretti et al., 2012) deserves a mention for its wide usage (Cohen et al., 1997; Cohen & Hoberman, 1983; Crane & Constantino, 2003; Hyman et al., 2003).

Although the effects of R/S on BD have not been extensively studied, available literature supports the beneficial effects of R/S and its coping mechanisms on both physical and mental health. During a 3-year follow-up among patients with chronic psychosis, Mohr et al. found that a positive use of religion can lead to a decrease in negative symptoms, an improvement in quality of life and better social functioning (Mohr & Huguelet, 2004; Mohr et al., 2010, 2011). The results of their literature review in 2011 led Barbara Pesut and her colleagues to suggest that R/S could be a relevant factor in managing BD and to conclude that it should be included in therapeutic pathways to develop well-being (Pesut et al., 2011).

While Jackson et al. (2022) found there is a lack of empirical research regarding R/S in BD patients, they noted from their scoping review that the measures of clinical outcomes indicate that intrinsic religiosity and religious beliefs and practices have highly positive correlations with improvement of bipolar disorder symptoms. They also reported that their participants felt that this area (even though sometimes difficult for them to discuss) should be taken into account by clinicians. The BD patient’s relationship with their self, with their identity, is a crucial issue in BD and R/S is an important factor in identity. There is clinical evidence to show that a full psychiatric anamnesis should include a patient’s spiritual history, as religion and spirituality are central components of the human experience and can influence the onset of mental illness and its course. Santambrogio et al. (2021) found there is increasing interest in the positive and negative impact of religion and spirituality on mental health, but like Jackson et al., the authors noted that little research has been done on how to approach these issues among people with serious mental illness (SMI). These authors also found that R/S can be simultaneously beneficial and detrimental for SMI sufferers; delusions and obsessions often contain religious content but this can also be seen as the search for a meaning throughout the course of a mental illness. These patients have the same religious and spiritual needs as the general population, and they seek the same support and meaning; many have histories of trauma and feel wounded in ways that religion and spirituality can help to address.

Religiosity is connected with mood symptoms and quality of life in BD. André Stroppa and his colleagues evaluated 168 BD patients with different scales in a cross-sectional study (Stroppa & Moreira-Almeida, 2013); the authors concluded that when patients have intrinsic religiosity and their religious beliefs and practices are positive, they tend to be less depressed and have a better quality of life, while the opposite is true when religious coping less strong. In a subsequent study with the same 168 individuals in a 2-year follow-up period, these authors concluded that, in addition to pharmacotherapy, R/S can provide a positive contribution to the state of mind of BD patients (Stroppa et al., 2018). However, another study with a sample of 189 Austrians and 180 Japanese, of whom a total of 120 diagnosed with BD, found spiritual well-being rather than religiosity was associated with resilience (Mizuno et al., 2017). Indeed, spirituality, in the sense of meaning, peace and purpose in life as opposed to religiosity or engagement with formal religious traditions per se, appears more closely linked to psychological resilience in patients with this disorder.

Mario Cruz and his colleagues (Cruz et al., 2010) noted that BD patients in mixed states tend to be more active religiously than patients in depressed, euthymic or manic states. In a review written in 2015, Pasquale De Fazio and his colleagues (De Fazio et al., 2015) noted that while R/S could be a psychosocial variable during the course of the illness, they found no support for the possibility of R/S providing protection or provocation in depressive or hypomanic phases; they also underline how different forms of R/S could reflect specific phases of BD, e.g., mystical and delusional thoughts may be present in manic phases that have psychotic elements (Pierre, 2001; Raab, 2007). From this point of view, R/S can provide an indication of the clinical state; however, mystic delusions must be distinguished from “spiritual emergencies,” defined by Alexander Moreira-Almeida and Harold Koenig as “critical phases linked with deep psychological changes with unusual experiences involving conscience, affectivity, thought, sense-perception and physical symptoms” (Moreira-Almeida & Koenig, 2006).

The majority of the articles examined in the course of writing this article express the need for further study of the relationship between BD and R/S.

During her years in AS.FRA., P. participated in the “Gospel and Zen” community and attended weekly Mass, as religion was important to her. During her manic phases in 2018, she had spiritual experiences that could be defined as visual hallucinations; moreover, she remembers standing in her garden, dressed in a kimono, listening to voices, the voices of her neighbors but also the voices of plants and God. In that period, her scores regarding participation in organizational and non-organizational religious activities remained unvaried, but the measurement of intrinsic religiosity decreased (from 12 to 10). In fact, mood instability caused her to feel insecure about the presence of the Divine, which underlies her whole approach to life. She also had delusional thoughts related to her participation in the “Gospel and Zen” community (“I am a Zen monk”). When she was depressed, she perceived religion as a way to atone for her sins. It is interesting to note that when P. took her medication as prescribed and attended her psychiatric visits regularly, her approach to R/S became less obsessive and healthier, and a more integrated aspect of her identity (Johnson et al., 1999). In 2019, when her clinical condition improved, her participation in organized religious activities increased (from 5 to 6) and so did intrinsic religiosity (from 10 to 13). During 2020, the year most affected by the COVID-19 pandemic when outside activities were forbidden, she spent more time in the community and her participation in non-organizational religious activities increased, e.g., reciting the rosary, Bible reading and meditation (from 2 to 6). She was able to participate in the “Gospel and Zen” community activities and attend weekly Mass at ASFRA with a clearer consciousness. Her R/S beliefs consolidated and matured in the ambit of the inter-religious community led by the two priests and the religious activities connected to the preparation of the Mass with the officiating priest in AS.FRA. Indeed, an interplay between the R/S dimensions and the perception of social support could be assumed. Having a role in this community and participating in these activities reinforced her faith; it became more tangible to her and therefore she perceived it as more supportive (Montgomery & Åsberg, 1979). The improvement in R/S scores could be related to the improvement in overall ISEL score, in particular in the Appraisal Support Subscale. Moreover, her association with the priests in their role as authoritative religious figures, helped her to feel embraced by a father figure. Since the onset of P.’s psychiatric disorder can be collocated as following the death of her biological father, experiencing a bond with a father figure (be it the Deity or human fathers, the priests) in the context of R/S provided an opportunity for healing. In 2021 all her R/S scores decreased slightly, as she developed a more balanced approach to this dimension.

With regards to clinical stability, P.’s mood became more stable over the 3-year follow-up. She arrived in a hypomanic state in 2018, became depressed in 2019 and then balanced from 2020 until the end of this report. She developed a deeper awareness about her condition and the need to follow medical prescriptions, “I feel good because I take these medications,” she reported, as opposed to, “I feel good, so I can reduce or stop medications.” This led P. to modify her requests, as she now then understood that proper therapy helped her have a more balanced relationship with reality, and she no longer experienced mood instability, emotional outbursts, and psychotic symptoms. She was able to participate in many activities and have healthy relationships. Moreover, since 2018, she perceived the activities and the group to which she belonged were a way “of stopping the mind from thinking about her financial situation.”

Over the years, P. has started to feel recognized and valued in a wide range of group contexts, because she was able to express her cultural and social abilities. She also experienced satisfaction in sharing time and experiences with friends and significant others. As her psychiatric and psychological pathway progressed, P. became increasingly confident about the possibility of going back home to live and her perspective became more autonomous. She saw that friends and relatives supported her decision and were available to help her, even in practical situations regarding the house.

In general, the limitation of single case studies is the difficulty of applying the findings to a wider population. However, we considered that the results from the evaluations from this case and the diagnostics could provide a useful contribution to a field where relatively little research has been done.

P.’s psychiatric history is complex and although she has accepted the diagnosis of BD, even identifying with it, finding the correct balance of psychotropic medication and social care has been challenging. Her fears for the future and lack of self-confidence led her to request comprehensive care and hospitalization, despite being financially autonomous and with a home of her own. In the long term however, the psycho-dynamically oriented psychiatric pathway of her rehabilitation program is helping her to become more self-confident and receptive to the idea of having a future in her own home. Her case shows how the clinical features of BD are connected not only to medical aspects but also to the psychosocial dimensions such as rehabilitation treatment (Colom et al., 2003), social support (Johnson et al., 1999) and R/S that constitute her identity.

In this case study, we have seen that when the patient’s mood was stabilized, R/S was an important factor that contributed to maintaining and increasing this stability, leading the patient to be more receptive to experiencing R/S positively in physical contexts (e.g., religious groups), which increased a positive perception of social support, further consolidating stability.