Bipolar Disorder Kim Carter Appalachian State University

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Bipolar Disorder

• Kim Carter
• Appalachian State University

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What is Bipolar Disorder ?

• It is a spectrum of affective episodes including
• Major depressive episode
• Manic episode
• Mixed episode
• Rapid cycling
• Hypomanic episode

• The DSM-IV categorizes it into
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymia
• Bipolar N.O.S.

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Bipolar I or II Disorder ?What is the difference?

• Bipolar I
• 1 manic or mixed episodes
• May have other mood episodes

• Bipolar II
• 1 major depressive episodes AND
• 1 hypomanic episodes
• Never manic or mixed episode

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Prevalence Rates and Course

• Bipolar I
• Lifetime .4-1.6
• in men and women
• Mengtmanic episodes
• Womengtdep episodes
• Womengtrapid cycling
• Ave. age onset 20
• Recurrent
• 60-70 of manic episodes occur before or after a
  depressive episode

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Prevalence Rates and Course

• Bipolar II
• Lifetime .5
• May be more common in women than men
• Mengthypomanic than depressive episodes
• Womengtdepressive than hypomanic episodes
• Womengtrapid cycling
• 60-70of hypomanic episodes occur before or after
  a depressive episode
• Interval between episodes decrease with age
• Less data overall

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Cyclothymic Disorder

• Chronic fluctuating periods of hypomanic and
  depressive symptoms for a 2 year period, absence
  of symptoms lt 2 months
• Lifetime .4-1, equal among men/women
• Onset adolescence or early adulthood
• 15-50 risk of developing into Bipolar Disorder

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Bipolar Disorder N.O.S.

• Rapid cycling (days) between manic and depressive
  symptoms
• Recurrent hypomanic episodes without intercurrent
  depressive symptoms
• Hypomanic episodes, along with chronic
  depressive symptoms, that are too infrequent to
  qualify for a diagnosis

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Etiological Factors

• Hereditary Factors
• Biochemical Hypothesis
• Stressful Life Events
• Cognitive Styles as Vulnerabilities

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Hereditary Factors

• 1st degree relatives have significantly higher
  rates
• Twin and adoption studies indicate genetic
  vulnerability
• May reflect environmental factors

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Biochemical Hypothesis

• Deficiency in norepinephrine
• Dopamine implicated in the study of mania and
  psychotic symptoms
• Serotonin levels have also been implicated

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Stressful Life Events

• Linkage between significant life events and
  affective abnormalities
• Negative, traumatic life events trigger mania
• Low social support, low self-esteem trigger
  depressive

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Family Environment

• Expressed Emotion may be an important
  factor-families with high expressed emotion have
  poor coping skills
• Families with high levels of EE are linked to
  greater levels of symptom relapse and poor
  treatment outcome, as compared to clients in
  families with low levels of EE

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Cognitive Styles as Vulnerability Factors

• Individuals with negative attributional styles
  combined with stressful life events can predict
  hypomanic, manic and depressive mood shifts
• Mania and depression are related to an ongoing
  sense of low self-worth

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List of Prognostic Indicators of Treatment
Outcome

• Suicidality
• Presence of a personality disorder
• Quality of family and social support
• Substance use
• History of severity of prior episodes
• Bipolar I type is most severe
• Treatment onset-the sooner the better
• Age of onset-the younger the more severe

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Bipolar Disorder-Major Public Health Issue

• Overall economic burden is estimated at 45
  billion dollars annually
• Costs of treatment for an individual exceed
  17,000 per year
• 1 in 3 people with bipolar disorder fail to
  comply with medications
• Non-adherence to treatment often results in
  hospitalization and suicide

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B.D. is often comorbid with other disorders.
Differential diagnosis should also be considered.
Specifically with

• Bipolar vs. unipolar
• ADHD
• Schizophrenia
• Substance abuse
• Axis II

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Substance Abuse and Bipolar Disorder

• B. D. is the highest Axis I disorder
  comorbid/concurrent with substance abuse
• 21-61 of people with B.D. abuse or are addicted
  to substances as compared to 3-13 in the general
  population
• B.D. is second to antisocial personality disorder
  in terms of concurrent substance abuse
• Substance use adversely effects medication,
  produces earlier onset of symptoms and often
  leads to hospitalization

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Bipolar Disorder and Personality Disorders

• Approximately 50 of all Bipolar patients also
  meet criteria for a personality disorder
• The most common comorbid conditions are in
  cluster B and C
• The most common Cluster B disorders include
  Antisocial, Borderline, Histrionic, Narcissistic
• The most common Cluster C disorders include
  Avoidant and Obsessive-Compulsive

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Major Issues that Impede Diagnosis and
Recognition of B.D.

• Lack of reliable assessment tools for Bipolar
  Disorder
• Misdiagnosed as unipolar depression
• Children, adolescents and young adults are often
  diagnosed with ADHD
• People often do not have clear cut, discrete mood
  episodes
• Mania if often unrecognized or considered
  irritability/ aggression
• Psychotic features are often mistaken for
  Schizophrenia
• Unwillingness of the client to seek treatment
• Lack of insight from client in mood episodes
• Clinicians are not looking for manic/hypomanic
  episodes- and reliance on self-reports

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Major Issues that Impede Diagnosis and
Recognition of B.D.

• Clinicians are not always looking for
  manic/hypomanic episodes and have a strong
  reliance on self-reports
• NOT forming a strong alliance throughout
  assessment period
• Poor assessment by the clinician of family and
  personal history
• Denial/Stigma may cause clinicians to under
  diagnose and clients may not accept the diagnosis

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Treatment Overview-phase I

• Perform a careful diagnostic evaluation
• Ensure the safety of client and consider the
  proper treatment setting
• Establish maintain a strong alliance
• Continually monitor psychiatric status
• Referral to psychiatrist

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SUICIDE RISK Must Be Continually Monitored

• Suicide completion rates in patients with B.D.
  10-15
• Presence of suicidal or homicidal ideation,
  intent, plans
• Access to means
• Psychotic features, severe anxiety
• Substance abuse
• History of previous attempts
• Family history or recent exposure

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Assessment Procedures

• Conduct a solid structured clinical interview
• Obtain a longitudinal hix of mood episodes
• Conduct careful observations of the client in
  session. Collect third party reports on data from
  various sources in a variety of settings ie.
  home, work, school
• Obtain a family history of illness. Remember to
  ask detailed questions beyond Has anyone been
  diagnosed with Ask questions geared around
  common symptoms like, do you have any relatives
  that committed suicide, extremely impulsive,
  abuse substances

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Assessment Tools

• The following tools will aide in the evaluation
  and diagnosis of a client
• PAI, MCMI
• The Mood Chart (Social Rhythm Metric)
• Mood Disorder Questionnaire
• Self-Control Behavior Scale
• Beck Depression and Hopelessness Inventories
• Basc inventories for 3rd party reports

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Continue to Evaluate and Provide Safety Nets
Throughout the Process

• Evaluate treatment setting- in or out patient,
  safety of the home
• Contract for safety and have a crisis plan with
  clients to reduce risk of suicide
• Inform and educate family about risks and
  triggers
• Limit access to weapons, cars, credit cards, bank
  accounts, etc.

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Therapist Variables

• The therapist has a large impact on treatment
  outcome
• Positive Predictors
• Maintain a strong therapeutics alliance
• Consider the family or couple as a system and
  integrate them into the treatment plan
• biopsychosocially understand, integrate and
  focus on medication compliance although
  psychosocial issues may seem more interesting and
  pressing

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Treatment Overview-phase II

• Educate the patient and family
• Enhance treatment adherence
• Promote awareness of stressors
• Anticipate and address signs of relapse
• Management/Maintenance/Improvement

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Psychoeducation for
family and client

• The patients and family should be educated about
  Bipolar Disorder as an illness, using the
  Diathesis Stress Model. Explain that there is a
  strong genetic component and that stress can lead
  to, or trigger, an episode. Through treatment,
  clients will learn to problem-solve, limit mood
  swings, and establish routines to help avoid
  unnecessary stressors.

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Psychoeducation for family and
client

• Refers not only to the illness, but also the
  treatment approach
• Explain and outline, in basic terms, the tx plan
• Explain the need for cooperation of client and
  family

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Specific Interventions

• Medication-refer to psychiatrist
• Interpersonal Social Rhythm Therapy
• Cognitive Behavior Therapy
• Family, couples therapy
• Group therapy

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Psychosocial Treatments are useful for Bipolar
Disorder by

• Increasing medication compliance
• Improving quality of life
• Enhance coping mechanisms for stress

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Psychosocial InterventionsInclude individual,
family and group psychotherapies

• The main goals
• Educate about illness and tx
• Enhancing acceptance of illness
• Improve monitoring of changes in mood, sleep and
  vigilance for warning signs of relapse
• Establish skills for coping with and limiting
  stress

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Psychosocial Interventions

• Main goals continued
• Identifying interpersonal difficulties commonly
  arising from being ill and refining skills for
  managing them
• Deriving support and encouragement from sharing
  experiences with others living with Bipolar
• Managing adverse experiences with long-term
  pharmacological tx
• Reducing the amount of EE in the home environment
• Dealing with the impact of the disorder on family

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Interpersonal and Social Rhythm Theory

• Based on the hypothesis that stressful life
  events affect the course of the illness in part
  by disrupting daily routines and social rhythms
  (sleep-wake cycles)
• Disruption in social rhythms in turn disrupts the
  circadian cycles
• Encourages clients to recognize the impact of
  interpersonal events on social and circadian
  rhythms

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Interpersonal and Social Rhythm Theory

• Two main goals-help clients recognize and
  understand the social context associated with
  mood disorder symptoms and to encourage clients
  to recognize the impact of interpersonal events
  on their social and circadian rhythms
• Regulate rhythms to in order to gain control over
  their mood cycling.
• Final goal is to identify and understand
  interpersonal problem areas-grief over the loss
  of their healthy self, interpersonal disputes
  and deficits, role transitions

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Interpersonal and Social Rhythm Theory

• Social Rhythm Metric-self monitoring chart for
  activity, stimulation, mood, times to understand
  the dynamics of social and circadian rhythms
• Clients learn balance in daily patterns of social
  activity, patterns of social stimulation and
  sleep cycles
• Clarifying and interpretive interventions for
  interpersonal interactions
• Learn to label problematic interpersonal patterns

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Cognitive Behavior Therapy

• Basic understanding that mood swings are partly a
  function of negative thinking patterns
• Alleviated through behavior activation and
  cognitive restructuring strategies
• Four stage process beginning with psychoeducation
  and presenting the Diathesis-Stress Model

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CBT Diathesis Stress Model

• Using cognitive skills to weigh against emotional
  waves and behavioral impulses
• Improving hopefulness to reduce risk of suicide
• Weigh pros and cons of important life decisions
  more methodically and with greater objectivity
• Modifying perceptions of marital and family
  interactions
• Reducing the harmful sense of stigma and shame

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CBT-Four phase strategy

• 1. Psychoeducation
• 2. Introduce cognitive behavioral skills to cope
  with mood episodes. Many clients find it hard to
  distinguish between mood episodes and prodromes.
  Using techniques like the mood chart and
  self-monitoring clients are taught to minimize
  goal directed behavior during mania and immobile
  behavior during depression.
• This model of how thought, behavior and mood
  affect each other helps clients grasp the CBT
  techniques.

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CBT-Four phase strategy

• 3. Importance of routine sleep- it has been
  observed that disruption in sleep cycles may lead
  to more episodes. Clients are exposed to
  behavioral skills such as activity scheduling as
  a useful means of establishing systematic
  routines
• 4. Dealing with long term vulnerabilities-carefull
  y assessing past triggers allows the client to
  identify themes that may help in future relapse

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CBT and Bipolar Disorder

• NOT talk therapy, requires active collaboration
• Structure of session-
• assessing weekly mood chart
• reviewing homework
• prioritize topics
• open ended questions to facilitate alternative
  ways of thinking about situations
• feedback
• assign new homework

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CBT techniques

• Teach self-monitoring with thought records
• Advance problem solving
• Maximize homework adherence
• Assessing schemas-target long standing cognitive
  vulnerabilities
• Recognize negative life events as triggers
• Continued goal setting

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Family and Couples Therapy

• Designed for problem solving and communication
  training for couples and families
• Psychoeducation should address guilt, shame, fear
• Life issues will remain, but the ability to cope
  is greatly improved
• Family environment may be altered to prevent
  future relapse-minimize EE, remove weapons
• Enhances overall treatment compliance for the
  client and improves quality of life
• May be ongoing (in conjunction with other
  treatments ie. medication, individual therapy)
  and later as crisis management

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Group Therapy

• Various group programs available, but they all
  have basically the same features
• Begins with psycho-education-usually 5 sessions
• Combines techniques from CBT and IPSRT-usually
  6-10 sessions
• Focus on relapse prevention, understanding
  triggers
• Dialectical Behavior Treatment can be an
  effective group format for clients

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Termination

• Consider the dental model-tx never really ends,
  but becomes maintenance
• Stress the need to continue medication
• Booster sessions may provide the client with
  necessary help
• Solidify good self-help habits to reduce future
  relapse
• Consider crisis management and develop a plan

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References

• American Psychiatric Association Steering
  Committee on Practice Guidelines (2004). Practice
  guidelines for the treatment of patients with
  bipolar disorder, In American Psychiatric
  Association Practice Guidelines for the Treatment
  of Psychiatric Disorders Compendium 2004 (pp.
  526-612). Arlington American Psychiatric
  Association.
• Buaer, M. McBride, L. (1996). Structured Group
  Psychotherapy for Bipolar Disorder The Life
  Goals Program. New York Springer Publishing
  Company.
• Huxley, N., Parikh, S. Baldessarini, R. (2000).
  Effectiveness of psychosocial treatments in
  Bipolar Disorder State of the evidence. Harvard
  Review of Psychiatry, 8, 126-140.
• Nathan, P. Gorman, J. (2002). A Guide to
  Treatments That Work. New York Oxford University
  Press.
• Newman, C., Leahy, R., Beck, A.,
  Reilly-Harrington, N. Gyulai, L. (2002).
  Bipolar Disorder A Cognitive Therapy Approach.
  Washington, D.C. American Psychological
  Association.
• Rivas-Vazquez, R., Johnson, S., Rey, G., Blais,
  M. Rivas-Vazquez, A. (2002). Current treatments
  for Bipolar Disorder  A review and update for
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  and Practice, 33, 212-223.
• Vieta, E. Colom, F. (2004). Psychological
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• wishful thinking to an evidence-based
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