# Traumatic Stress and Psychological Trauma Therapy in Bipolar Disorder

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- Page title: Traumatic Stress and Psychological Trauma Therapy in Bipolar Disorder | Assoc. Prof. Dr. Alişan Burak Yaşar

> Comorbid post-traumatic stress disorder in bipolar disorder and the role of trauma-focused psychotherapies, particularly EMDR.

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# Traumatic Stress and Psychological Trauma Therapy in Bipolar Disorder

June 9, 2025Articles in Bilim ve Ütopya

[Görsel: Traumatic Stress and Psychological Trauma Therapy in Bipolar Disorder]

Bipolar disorder is a psychiatric illness characterized by episodes of depression and mania/hypomania that, if left untreated, significantly impairs the quality of life of both the individual and their loved ones. Manic episodes are a particularly prominent feature of bipolar disorder, involving increases in energy, self-confidence, and a sense of inner strength; reduced sleep, increased sexual desire, and increased goal-directed activity accompanied by an elevated or irritable mood. In the section prepared by Prof. Dr. Kürşat Altınbaş in this special feature, you can find a more detailed introduction to the illness. The other side of bipolar disorder consists of depressive episodes, which are sometimes less readily recognized than mania. These depressive episodes can easily be confused with the more common “unipolar” depression—that is, depression that is not bipolar. During the depressive phases of bipolar disorder, we may sometimes encounter treatment-resistant depressive symptoms. Although we have effective medications for the depressive phase of bipolar disorder, just as we do for mania, depressive episodes can sometimes impair quality of life to a distressing degree despite medication. It is precisely at this point that we may need to discuss the “stress-related” effects superimposed on the biological features of bipolar disorder…

## Bipolar disorder as a biological illness

When we consider psychiatric illnesses, it is sometimes possible to link anxiety disorders, post-traumatic stress disorders, and unipolar depression to life events, situations involving traumatic stress, or individuals’ cognitive interpretations. For this reason, we can often recommend talking treatments, which we call psychotherapy, for these conditions—historically described as “neurotic”—particularly when they are mild to moderate in severity. By contrast, bipolar disorder and certain psychotic disorders differ from this “neurotic” group in that they are more closely related to the brain’s underlying structural functioning and have better-defined biological features. In other words, the biological component of bipolar disorder is prominent, and biological factors play a greater role in its causation. This is why treating bipolar disorder generally requires medications specifically indicated for the condition and proven effective through research. You can also read more about the treatment of bipolar disorder in the section prepared by Prof. Dr. Devran Tan in this issue.

In many psychiatric illnesses, and indeed in a substantial proportion of medical illnesses, other conditions frequently accompany the illness responsible for the main presenting complaint. We call this comorbidity. Sometimes, the prominence of one illness can cause these comorbid conditions to be overlooked. When this happens because of stigma or a lack of awareness, important opportunities to improve quality of life may be missed.

## A major barrier to seeking treatment: Stigmatization

Stigma is an umbrella term with three main components: ignorance (a problem of knowledge), prejudice (problems of attitude), and discrimination (a problem of behavior). Stigma surrounding mental health and psychiatry leads to discrimination against people with psychiatric disorders, making it one of the greatest barriers to early and successful treatment (Latalova et al., 2013). At this stage, comorbid conditions may not be reported as complaints and may be overlooked because of the stigma surrounding bipolar disorder and its striking clinical features… In the section prepared by Prof. Dr. Kaan Kora in this special feature, you can read more about stigma and its psychological effects. In this context, at a psychological level, internalized stigma and social anxiety can cause distress that may even trigger symptoms of bipolar disorder. This internalized stigma can inhibit attempts by patients with bipolar disorder to seek help for various complaints related to both their primary illness and comorbid conditions. Thus, stigma can both reduce treatment-seeking among patients with bipolar disorder and contribute to stress-related comorbid mental illnesses.

## Bipolar disorder and comorbid conditions

The most common mental disorders co-occurring with bipolar disorder include anxiety disorders, substance use disorders, and conduct disorders. In clinical samples, eating disorders, attention-deficit/hyperactivity disorder, impulse-control disorders, sexual problems, autism spectrum disorders, and Tourette’s disorder may co-occur with bipolar disorder. Among non-psychiatric conditions, the most common general medical comorbidities are migraine, thyroid disease, obesity, type 2 diabetes, and cardiovascular disease (McElroy, 2004). Today, we have highly successful, evidence-based treatment options for these co-occurring general medical and psychiatric conditions. Various medications are also available for many of these comorbid psychiatric illnesses. Although some are also recommended for bipolar disorder, others require extreme caution when used in this condition. As with many illnesses in which the biological component is so prominent, psychotherapy options alongside medication may be overlooked in bipolar disorder, even though they can play a critically important role in quality of life.

## Bipolar disorder and psychotherapies

Research on various psychotherapies for bipolar disorder shows that although pharmacotherapy (medication treatment) is the foundation of treatment, medication alone may not be sufficient for patients to achieve full well-being in every area of life. With pharmacological interventions alone, relapse rates may increase, and residual symptoms and psychosocial impairments may persist. Evidence shows that, when added to medication, bipolar-specific psychotherapies offer advantages over medication alone in terms of symptom burden and relapse risk. A literature review examining 28 randomized controlled trials of individual or group psychosocial interventions for adults with bipolar disorder found that those receiving bipolar-specific psychotherapy, whether individually or in groups, made better progress than those who did not (Swartz & Swanson, 2014). Although psychiatric care and pharmacotherapy are fundamental components of bipolar disorder treatment, certain forms of psychotherapy are also critical components of the treatment plan for many patients. Patients with bipolar disorder suffer from the psychosocial consequences of past episodes, thoughts about the possibility of future episodes, and the burden of adhering to a long-term treatment plan that may occasionally cause side effects. Most patients with bipolar disorder struggle with some of the following issues:

- 1) The emotional consequences of manic and depressive episodes;
- 2) Thoughts about having a potentially chronic psychiatric illness;
- 3) Stigma-related problems;
- 4) Delays in treatment or major departures from the treatment plan;
- 5) Fear of recurrence and the resulting concerns about everyday life;
- 6) Difficulties related to marriage, family, childbearing, and parenting, as well as other interpersonal difficulties;
- 7) Academic and occupational problems;

8) Other legal, social, and emotional problems resulting from withdrawn or uncharacteristic behavior that may occur during episodes.

The most extensively studied psychotherapeutic approaches for these issues are psychoeducational, interpersonal, family, and cognitive behavioral therapies (Hirschfeld et al., 2002). In this context, the following stand out as bipolar-specific psychotherapy approaches:

- 1) Psychoeducation,
- 2) Cognitive Behavioral Therapy
- 3) Interpersonal and Social Rhythm Therapy (IPSRT)
- 4) Family-Focused Therapy (FFT)
- 5) Approaches such as group therapy (Ulaş, 2017).

## Bipolar disorder and post-traumatic stress disorder

Among comorbid psychiatric illnesses, I would like to discuss post-traumatic stress disorder (PTSD), which is frequently seen in patients with bipolar disorder, and “trauma-focused psychotherapies” in a little more detail. Post-traumatic stress disorder is defined by the development of specific symptoms, such as re-experiencing, avoidance, alienation, and hyperarousal, lasting more than one month after a person experiences a traumatic event or witnesses or learns of a traumatic event involving loved ones, with resulting impairment in social and occupational functioning.

In bipolar disorder, we can divide traumatic events into those that occurred before the illness and those related to the illness.

## Bipolar disorder and illness-related trauma

As with diabetes (Öztürk, 1997), hypertension, and similar conditions, receiving a diagnosis of bipolar disorder can create varying levels of stress for some patients, depending on how they make sense of it. Following diagnosis, with appropriate information and proper treatment, the great majority of patients with bipolar disorder can lead healthy lives like the rest of the population. We observe that this stress decreases once patients experience successful treatment outcomes. Sometimes, however, when the first manic or depressive episode is unexpected and severe, the experiences people have during that period of their lives can have a different kind of traumatic impact. Although uncommon, periods of hospitalization for more effective treatment can also have a different kind of traumatic impact on some patients. Of course, viewed from the opposite perspective, if hospitalization is genuinely necessary, going through an episode without being admitted may be more traumatic, and rapidly recovering from the episode in hospital may be considered protective against traumatic stress. Taken together, it would not be wrong to say that patients with bipolar disorder are at considerable risk of psychological trauma and its psychological effects.

In addition, episodes of bipolar disorder can sometimes be triggered by stressful life events. Even the very first episode may be triggered by a stressor. Studies have not identified a single genetic factor contributing to the onset of the disorder. For this reason, the biopsychosocial model is critically important when assessing the onset of this disorder, as it helps identify environmental triggers that can precipitate illness in the presence of genetic susceptibility (Koenders et al., 2020).

In other words, when patients with bipolar disorder experience a loss, go without sleep for several days for various reasons, or experience other distressing events, their underlying illness can be triggered, leading to a manic or depressive episode.

## Bipolar disorder and psychological trauma

We also know from the literature that people with more extensive childhood trauma are more sensitive to stress. Studies on this subject suggest that exposure to childhood trauma during neurodevelopmental stages early in life, including young adulthood, contributes to an increased risk of developing bipolar disorder (Quidé et al., 2020). This process may be related to disruption of the psychological and biological systems that mediate responses to stressful events (Quidé et al., 2020). Individuals with bipolar disorder who have been exposed to childhood trauma develop more severe clinical manifestations of the disorder, are diagnosed earlier, and are more likely to engage in self-harm and develop other mental and physical illnesses. Stress may also affect the course of established bipolar disorder. Exposure to stress, particularly interpersonal stressors, as well as psychological trauma, has been shown to have detrimental effects on the course of bipolar disorder. Consistent with stress-generation models, some papers suggest that people with a history of trauma are more vulnerable to chronic interpersonal stressors associated with more severe depressive symptoms (Gershon et al., 2013). Thus, beyond its high prevalence in bipolar disorder, trauma may predict a more difficult course involving more severe mood symptoms and an increased tendency toward self-harm (Maguire et al., 2008).

Let us look at a study on this subject. In a study investigating post-traumatic stress disorder in 405 people with bipolar disorder, participants were divided into three groups:

- a. Patients with bipolar disorder and post-traumatic stress disorder,
- b. Patients with bipolar disorder who had been exposed to trauma but did not have post-traumatic stress disorder
- c. Patients with bipolar disorder who had not been exposed to trauma.

The group with comorbid post-traumatic stress disorder reported poorer quality of life, more rapid cycling, higher rates of self-harm attempts, and a lower recovery rate. The findings associated post-traumatic stress disorder with less benefit from treatment, more rapid cycling, an increased risk of self-harm attempts, and poorer quality of life (Quarantini et al., 2010). Another study evaluated a total of 74 patients diagnosed with bipolar I disorder (m = 30, f = 44). Of the participants, 37 patients (50%) reported no trauma, 22 (29.7%) had experienced a traumatic event without a diagnosis of post-traumatic stress disorder, and 15 (20.3%) had comorbid post-traumatic stress disorder. In this group with bipolar disorder, rates of post-traumatic stress disorder and exposure to physical violence, parental neglect, parental alcohol dependence, and sexual assault by a family member or acquaintance were higher than in the general population. These findings indicate that patients with bipolar disorder are more likely to experience traumatic events, with post-traumatic stress disorder emerging as a comorbid condition. Post-traumatic stress disorder is also associated with greater severity of bipolar disorder. We see that post-traumatic stress disorder is significantly associated with traumatic experiences within patients’ families and with parental alcohol dependence as a risk factor (Assion et al., 2009). Another study even shows that people with traumatic stress disorders have a substantially increased risk of bipolar disorder. In one study, the risk was highest within the first year following the diagnosis of a traumatic stress disorder and remained significantly elevated more than five years later (Okkels et al., 2017). Another study in adolescents examined rates of post-traumatic stress disorder among those with bipolar disorder and major depressive disorder (MDD, unipolar depression). The risk of post-traumatic stress disorder was found to be significantly higher in patients with bipolar disorder than in those with unipolar depression (Dilsaver et al., 2007). A very large review examined 20 studies involving 3,407 young people and adults with bipolar disorder across 10 countries and three continents, finding higher rates of various childhood trauma subtypes in patients with bipolar disorder than in healthy individuals (Maniglio, 2013). Therefore, post-traumatic stress disorder and traumatic stress-related disorders, which are not uncommon among patients with bipolar disorder, should be examined in detail, and trauma-focused psychotherapies should be considered if a traumatic stress-related disorder is identified.

## Psychotherapies for post-traumatic stress disorder

Patients with bipolar disorder experience comorbid post-traumatic stress disorder at a prevalence of approximately 20% (Cerimele et al., 2017). In addition to life events, symptoms of post-traumatic stress disorder contribute to more mood episodes (Simhandl et al., 2015). Trauma-focused interventions therefore need to be integrated into treatment strategies for patients with bipolar disorder (Perlini et al., 2020) (Valiente-Gómez et al., 2017). Because of stigma, the striking features of bipolar episodes, the relatively large amount of effort and attention required to treat an episode, continuing limitations in access to psychotherapy, financial difficulties in sustaining it, and other reasons, patients may not report co-occurring illnesses as complaints; these conditions may be overlooked, or patients may be unable to access psychotherapy for them. Stigma in society carries substantial risks, ranging from difficulties with treatment adherence to not seeking medical care for the illness at the appropriate time. Yet when post-traumatic stress disorder is present, considering trauma-focused therapies may offer significant clinical benefits. The International Society for Traumatic Stress Studies (ISTSS) specifically recommends Cognitive Behavioral Therapy (CBT), EMDR, Trauma-Focused CBT, and Prolonged Exposure therapy for adults with post-traumatic stress disorder (Hamblen et al., 2019). Could trauma-focused therapies specifically applied to bipolar disorder therefore be helpful in addition to essential pharmacotherapy and the usual psychotherapies for bipolar disorder? Let us now take a brief look at recent studies on EMDR therapy, one of the leading recommended psychotherapies for post-traumatic stress disorder, which originated as a trauma therapy and shows promise as an adjunct to standard treatment for bipolar disorder.

## Bipolar disorder and EMDR

Eye Movement Desensitization and Reprocessing (EMDR) is a psychotherapeutic approach initially developed to treat post-traumatic stress disorder (PTSD). More recently, it has been proposed as an adjunctive therapy for a wide range of clinical conditions. In particular, people with mood disorders such as bipolar disorder and major depressive disorder (MDD, unipolar disorder) have higher lifetime rates of traumatic or stressful life events than the general population. EMDR therapy may be a promising and safe treatment strategy for reducing trauma symptoms and stabilizing mood in traumatized patients with bipolar disorder. Specific EMDR protocols with tailored guidelines for particular patients with bipolar disorder have therefore been developed (Amann et al., 2015). Unfortunately, the available data on the use of EMDR in patients with bipolar disorder remain limited. Despite substantial limitations, scientific publications generally suggest that EMDR is a promising and safe intervention for treating both certain mood symptoms and trauma symptoms in traumatized patients with bipolar disorder. In addition to its beneficial effects on trauma-related symptoms, EMDR may have positive effects on manic and depressive symptoms when used alongside medication. A review of 15 studies, three focusing on bipolar disorder and 12 on major depressive disorder, provides preliminary evidence that EMDR is a useful adjunctive approach in treating bipolar disorder and major depressive disorder, particularly when other treatments have failed. Applying these trauma-focused treatments to larger patient samples with careful planning is now recommended (Perlini et al., 2020). In another study conducted at three different clinics in Spain, patients with bipolar disorder received EMDR or supportive therapy. This was a multicenter randomized controlled trial in which 82 patients with bipolar disorder and a history of traumatic events were assigned to one of the two treatments. Patients in both groups received 20 psychotherapy sessions, each lasting 60 minutes, over six months. The primary outcome was a reduction in mood episodes after 12 and 24 months in favor of the EMDR group. Secondary outcomes showed a greater reduction in affective symptoms and better cognitive and social functioning in the EMDR group. The results of this study provide new information suggesting that a specific EMDR protocol used as trauma-focused therapy for people diagnosed with bipolar disorder is effective in reducing mood episodes, affective symptoms, and functional, cognitive, and trauma-related symptoms (Moreno-Alcázar et al., 2017). In another small-scale study, twenty patients with bipolar I or II disorder who had subthreshold mood symptoms and a history of traumatic events were randomly assigned to Eye Movement Desensitization and Reprocessing therapy (n = 10) or a control group (n = 10). The treatment group received 14 to 18 EMDR sessions over 12 weeks. Mood symptoms, trauma symptoms, and the impact of trauma were assessed by a blinded assessor at baseline, at weeks 2, 5, 8, and 12, and at the 24-week follow-up. After the intervention, patients in the treatment group showed statistically significant improvements in depressive and hypomanic symptoms, trauma symptoms, and the impact of trauma compared with the usual-care group. This pilot study suggests that EMDR therapy may be an effective and safe intervention, alongside medication, for treating subthreshold psychiatric and trauma symptoms in traumatized patients with bipolar disorder. The results showed that EMDR not only reduced trauma-related symptoms but also had beneficial effects on subthreshold mood symptoms (Novo et al., 2014). Finally, a psychiatry specialty thesis study conducted in Sivas in 2017 by Dr. Cansu Ulaş investigated the use of EMDR therapy in patients diagnosed with bipolar disorder who had traumatic experiences, and whether it reduced general anxiety, trauma symptoms, and subthreshold symptoms during follow-up. Twenty-one volunteer patients with bipolar I or II disorder who were in remission were enrolled and divided into two groups, with 10 in the treatment group and 11 in the control group. Patients were followed for 24 weeks. In the therapy group, major traumatic memories with a continuing traumatic impact were selected through clinical interviews and assessments, then processed using EMDR therapy with a formulation specific to the traumatic event. Both the therapy and control groups continued medication throughout the specified period. The EMDR group showed significantly greater reductions in scores on trauma, depression, and anxiety scales than the control group. This study indicates that EMDR therapy has positive effects on bipolar symptoms, illness severity, anxiety, and post-traumatic stress disorder symptoms. It provides preliminary evidence that EMDR therapy may be a valid adjunctive treatment for patients diagnosed with bipolar disorder who have a history of trauma, but these findings need to be supported by longer-term follow-up studies with larger samples. One particularly welcome aspect of this study is that it was conducted in our country (Ulaş, 2017).

In conclusion, bipolar disorder is a treatable illness with a strong biological component, in which medication is a very important part of treatment. Nevertheless, we must not overlook other potentially co-occurring psychiatric illnesses or psychological trauma-related disorders, whether associated with bipolar disorder or independent of it. What we sometimes regard as the “treatment-resistant aspect” of bipolar disorder may actually be symptoms of another co-occurring syndrome that could benefit from psychotherapy. If so, adding effective methods used to treat those other syndromes to routine treatment may allow greater progress in managing these illnesses. A substantial number of patients with bipolar disorder recover fully between episodes, but some continue to exhibit residual mood symptoms (Paykel et al., 2006). One factor that may contribute to such symptoms is comorbid post-traumatic stress disorder, which has been found in 16–39% of patients with bipolar disorder and whose symptoms may persist between episodes, particularly alongside subthreshold manic symptoms (Otto et al., 2004). I believe that in the future we will see more research on adding trauma-focused psychotherapies such as EMDR, CBT, and Prolonged Exposure to routine treatment for people with bipolar disorder, who are at high risk of experiencing traumatic stress. If this happens, I expect these therapies to be routinely recommended as an option for enhancing treatment.

## References

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*This article was first published in the Bipolar Disorder special feature of Bilim ve Ütopya magazine (2025).*

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