Psychotherapy For Bipolar Disorder

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Psychotherapy For Bipolar Disorder

• Brooke Tompkins

2
Overview

• Bipolar Diagnoses
• History and Facts
• Etiology
• Cognitive-Behavior Therapy
• Interpersonal and Social Rhythm Therapy
• Empirical Support

3
DSM-IV Diagnoses
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DSM-IV Manic Episode

• Abnormally and persistently elevated, expansive,
  or irritable mood, lasting at least 1 week (or
  any duration if hospitalization is necessary).
• Three (or more) of the following symptoms have
  persisted (four if the mood is only irritable)
• inflated self-esteem
• decreased need for sleep
• pressured speech
• flight of ideas or racing thoughts
• distractibility
• increase in goal-directed activity
• increased involvement in pleasurable activities
  with a high potential for negative consequences

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DSM-IV Major Depressive Episode

• Five (or more) of the following symptoms have
  been present during the same 2-week period at
  least one of the symptoms is either (1) depressed
  mood or (2) loss of interest or pleasure.
• depressed mood most of the day, nearly every day.
  Note In children and adolescents, can be
  irritable mood.
• lost of interest or pleasure in activities
• significant weight loss or weight gain
• insomnia or hypersomnia
• psychomotor agitation or retardation
• fatigue or loss of energy
• feelings of worthlessness
• diminished ability to think or concentrate
• suicidal ideation

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DSM-IV Mixed Episode

• Symptoms of a Manic Episode and a Major
  Depressive Episode nearly every day during at
  least a 1-week period.
• cause marked impairment

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DSM-IV Hypomanic Episode

• Elevated, expansive, or irritable mood, lasting
  at least 4 days, that is clearly different from
  the usual non-depressed mood.
• Three (or more) of the symptoms of a manic
  episode have persisted (four if the mood is only
  irritable).
• The episode is uncharacteristic of the person
  when not symptomatic.
• Observable by others.
• Does not cause marked impairment in social or
  occupational functioning, and does not
  necessitate hospitalization.

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DSM-IV Bipolar Disorder

• Bipolar Disorder I
• At least one manic or mixed episode (lasting for
  at least a week) within his or her lifetime.
• A depressive episode is not a diagnostic criteria
• Bipolar Disorder II
• At least one episode of hypomania
• at least one episode of depression
• Rapid Cycling 4 or more episodes in a year
• Bipolar NOS

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DSM-IV Cyclothymic Disorder

• For at least 2 years
• hypomanic symptoms
• depressive symptoms
• Not without symptoms for more than 2 months at a
  time.

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Prevalence and Comorbidity

• Lifetime prevalence
• 0.8-1.6
• Current point prevalence 18 (NIMH) 2.6
• Median age of onset
• Late adolescence, early 20s
• Rate among adolescents is increasing (estimate of
  1)
• Comorbidities
• 50 with alcohol or substance abuse disorders
• 60 with anxiety disorders (Panic Disorder
  Social Phobia)
• 33-50 with personality disorders
• Comorbidity is the rule rather than the exception
• Associated with poorer course over time

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Diagnostic Issues

• One-third to one-half of bipolar I disorder
  patients experience psychotic symptoms (usually
  brief - less than 2 weeks)
• 40 of those with bipolar disorder are first
  diagnosed with unipolar depression (2004)
• Treated with antidepressants leads to about 25
  of these individuals experiencing iatrogenic
  manic symptoms
• Up to 75 do not adhere to medication regimens

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Etiology - Biological Basis

• Heritability as high as 80
• First-degree relatives
• 10 chance of bipolar disorder and unipolar
  depression
• Polygenic
• Involves a combination of several genes
• New research - genetic vulnerability traits
• How?
• Dysregulation of neurotransmitters
• Difficulties in maintaining homeostasis
• Symptoms likely under neurobiological stressors
  (i.e., sleep deprivation)
• Different brain activity

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Etiology Diathesis-Stress

• Biological predisposition stressful events
  subjective perception (cognitive triad)
• Negative life events predict bipolar depression
• Butcombined with a high behavioral activation
  system - triggers mania
• Excessive focus on goal attainment stimulates
  manic episode

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Etiology - Circadian Dysregulation

• Biological Rhythms
• Seasonal peaks
• Suicide
• Sleep patterns
• Social Rhythm Stability Hypothesis (Frank et al.)
• Changes in routine (sleep cycles, appetite,
  energy, work, etc.) can cause great stress on the
  body, especially in more vulnerable individuals

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Then and Now

• Most biological of severe psychiatric disorders
• Previously thought amenable only to
  pharmacotherapy
• Psychoanalysis not effective
• 1980s
• Improving pharmacological treatments
• Important challenge treating chronic subacute
  depressive symptoms
• Beginning of research on psychotherapy

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Pharmacotherapy

• First line of treatment
• Strongest support
• Lithium (1949) recommended by APA Practice
  Guidelines
• ¾ report side effects, leads to discontinuation
  and hospitalization
• Mood stabilizers are less effective in reducing
  depressive symptoms
• Mood stabilizers antidepressants
  antipsychotics
• Psychotherapy as adjunct to pharmacotherapy
• Know about medications!

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Why Psychotherapy?

• Provide psychoeducation regarding symptoms
• Promote adherence with medication regimens
• Address comorbid conditions
• Ameliorate stigma and self-esteem consequences
• Enhance social and occupational functioning and
  adjustment
• Reduce risk of suicide
• Identify psychosocial triggers that increase the
  risk for relapse
• Evidence suggests that psychosocial treatments
  both reduce and prevent symptoms

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Current Treatment Guidelines

• American Psychiatric Association, 2002
• Initiating mood stabilizing treatment
• Add one or more of the following
• Specific psychotherapy
• Antidepressant medication
• APA Practice Guidelines

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Supported Types of Psychotherapy

• Interpersonal and Social Rhythm Therapy (IPSRT)
• Cognitive-Behavior Therapy (CBT)
• Group or Individual Psychoeducation
• Family Therapy
• All trials of psychotherapy as complementary to
  pharmacotherapy (Swartz, Frank, Kupfer, 2006)
• Possible phase-specific treatments

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Differential effects of psychotherapies
Swartz, Frank, Kupfer, 2006
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Assessment of Symptoms

• Self-Report
• Mood Disorders Questionnaire (Hirschfield, 2002)
• Clinical Evaluation
• SCID-IV
• .61-.64 reliability
• .76-.78 reliability when used with medical
  records
• Assessment of Symptom Severity
• Inventory for Depressive Symptomatology (IDS-C
  Rush et al., 1986)
• Bech-Rafaelsen Mania Scale (Bech et al., 1979)
• Young Mania Rating Scale (YMRS Young et al.
  1978)
• Manic State Rating Scale (Beigel, Murphy,
  Bunney, 1971)
• Assess medication compliance
• Assess for suicide!

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Cognitive Behavior Therapy

• Focuses on the cycle of reactions to symptoms
  that impair functioning, cause psychosocial
  problems, and increase stress

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Cognitive-Behavioral Process

• Psychoeducation
• Reactive Symptom Management
• Symptom Monitoring/Develop Early Warning System
• Adherence to Treatments
• Symptom Control (CBT and cognitive strategies)
• Reducing Stress
• Generally around 12-20 sessions

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Every Session

• Collaborative agenda setting
• Mood and medication assessment
• Review homework
• Setting goals and priorities for session
• Assigning new homework
• Final summary and feedback

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Psychoeducation

• Explain disorder and role of cognition
• BD runs in families
• Involves biochemical problems that can cause
  symptoms such as anger, impulsivity, depression,
  suicidality, exuberance, hypersexuality, and a
  false sense of invinciblity
• Diathesis-stress disorder - biological problem
  interacts with stress
• Can be dangerous to health, relationships,
  occupational success, etc.
• Much due to cognitive triad
• Explain negative explanatory style
• Can be treated with both medication and
  psychotherapy

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Psychoeducation

• Explain purpose of CBT treatments
• Learn to adopt constructive outlook on life
• Problem-solving
• Improve quality of life
• Ease of medication adherence
• Less likelihood of relapse
• Introduce importance of homework
• Can assign reading materials for homework
• Finding Peace of Mind Treatment Strategies for
  Depression and Bipolar Disorder
• Bipolar Disorder

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Psychoeducation

• Knowledge of medication and adherence
• Why medication is used
• Side effects
• Mood stabilizing vs. antidepressant
• Expected outcome
• Long-term issues with management
• Why psychotherapy is needed in addition
• Identify issues to discuss with physicians
• Provide readings

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Managing Hypomanic/Manic Symptoms

• Recognize warning signs
• Interventions and Rules
• Medical solutions first
• Two-person feedback rule for great ideas
• Limit cash payments
• To counteract impulsivity
• Give car keys or credit cards to someone to keep
• Rules about staying out late or giving out phone
  
• Avoid alcohol and substance use
• minimize stimulation
• 48-hours before acting rule
• Treatment Contract

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Managing Hypomanic/Manic Symptoms

• Interventions (contd)
• Imagery about worst-case scenarios
• Relaxation techniques
• Diaphragmatic breathing
• PMR
• Address wish to stay manic
• They will feel more creative, productive,
  attractive, etc.
• Remind them that some of the worst events in
  their life have happened during manic episode
• Ultimately, decisions will lead to more
  disruption

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Symptom Monitoring

• Identify how day-to-day experiences are related
  to symptoms of bipolar disorder
• Ask how illness has affected their lives and home
  environment
• Complete Symptom Summary Worksheet
• List of symptoms
• Circle what they experience in episode
• Circle what they experience when normal
• Homework Provide copies for patient to add
  symptoms throughout the week
• Teach patient to monitor key symptoms, such as
  changes in mood
• Review Mood Graph in session, complete for
  yesterday and today
• Homework Keep mood graphs.
• Remember to always address homework at beginning
  of the next session

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Development of Early Warning System

• Complete Life Chart
• Reference line that represents a normal/euthymic
  state
• Draw episodes of mania, depression, and mixed
  states on timeline
• Draw first episode together, they complete the
  rest
• Can consult with family members, medical records,
  etc.
• Include types and dates of received treatment

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Development of Early Warning System

• Develop early warning system
• Distinguish between normal and abnormal mood
  shifts
• Using Symptom Summary Worksheet and Life Chart
• Make detailed descriptions of patient in normal
  and episodic states
• Descriptions used by patient, family members, can
  call therapist and review
• use mood graphs

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Treatment Adherence

• Introduce CBT model of adherence
• Noncompliance is the norm, not the exception
• Illness interferes with adherence
• New conceptualization of adherence
• Waxes and wanes over time
• Difficulties from family, differing opinions,
  anger at some medications not working, etc.
• Strategies to reform opinion on illness,
  medications, and necessity of treatment

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Compliance Contracts

• Assessment and Goals
• Review dosing schedules
• Review appointment plans
• Goals for homework assignments
• Identify Obstacles
• Intrapersonal
• Treatment
• Social system
• Interpersonal
• Cognitive
• Make plan for overcoming obstacles
• Ask about past successful strategies
• Make a plan
• Periodically review and modify if necessary

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Example Compliance Contract

• Step 1 Treatment Plan
• I, patient name, plan to follow the treatment
  plans listed below
• Take 900 mg of lithium at bedtime.
• Take 4 mg of Ambien to help me sleep.
• See the doctor every month and call if I think
  the regimen needs to be changed.
• Step 2 Compliance Obstacles
• I anticipate these problems in following my
  treatment plan
• If I continue to gain weight with lithium I may
  want to stop taking it.
• The Ambien might stop working and Ill need
  something stronger.
• When I get home late Im too tired to go to the
  kitchen to take my pills.

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Example Compliance Contract

• Step 3 Plan for reducing obstacles
• To overcome these obstacles, I plan to do the
  following
• Join Weight Watchers. Start walking in my
  neighborhood.
• Improve sleep by not drinking coffee or other
  caffeinated beverages after 4 pm.
• Keep the evening dose at the bedside with a
  bottle of water.

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CBT Strategies for Symptom Control - Manic

• Goal Testing Reality of Thoughts and Beliefs
• Discuss typical hypomanic cognitive errors
• overreliance on luck
• underestimating risk of danger
• overestimating capabilities
• disqualifying negative, minimization of lifes
  problems
• overvaluing immediate gratification
• misinterpreting intentions of others
• Discuss automatic thoughts and distorted
  cognitions
• If difficult to identify, describe general
  impressions and images until they can identify
  beliefs, themes, concerns
• Use Automatic Thought Records

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CBT Strategies for Symptom Control - Manic

• Alert them to the impact the thought has on their
  mood state
• Use behavioral experiments to test thought
• Consult with trusted others
• Examine evidence
• List evidence for/against
• Alternative explanations
• Cognitive restructuring to evaluate thoughts
• Homework Keeping Automatic Thought Records.

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CBT Strategies for Symptom Control - Manic

• Goal Modifying Behavioral Symptoms
• Negative Imagery
• Activity Scheduling
• A and B lists
• Plan activities ahead of time
• Can make a Daily Activity Schedule
• Increasing sitting and listening
• Sit when they notice they are speaking or moving
  rapidly in social situations interrupts
  acceleration of motor activity
• Focus on listening to others use self-statement
  prompts if needed
• Pay attention. Listen to name of person.
• Advantages/disadvantages technique

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Advantages/Disadvantages Technique
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CBT Strategies for Symptom Control - Manic

• Stimulus Control
• Knowing what activities to avoid
• Alcohol or other substances
• Unsupervised spending of large amounts of money
• Daredevil hobbies
• Exaggerated generosity or friendliness with
  strangers
• Activities using a lethal weapon
• Consulting with others
• Feedback

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CBT for Symptom Control Manic Depressive

• Sleep Enhancement
• Be consistent
• Its a nighttime thing
• Keep your bed a place for sleep
• Get comfortable
• Gear down for the night
• Avoid stimulants that might keep you awake
• Dont do
• Caffeine
• Internet
• TV and books
• Chores
• Exercise

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CBT Strategies for Symptom Control - Depression

• Goal Testing reality of negative thoughts
• Identification of Negative Automatic Thoughts
• Automatic Thought Record
• Evidence for/evidence against technique
• Alternative Explanations
• Patient chooses explanation that seems most
  likely
• Reframe thoughts of suicide
• Have them write down reasons to live
• Homework Keep Automatic Thought Records.

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CBT Strategies for Symptom Control - Depression

• Goal Increase behavior
• Discuss behavioral aspects of depression
• Normalize feeling overwhelmed and overloaded
• How have they coped with it in the past?
• Graded Task Assignment
• List all tasks that require attention
• Divide tasks into smaller steps
• Devise plan to guide patient from one step to the
  next
• A and B lists to help choose important tasks

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CBT Strategies for Symptom Control - Depression

• Goal Increase behavior (contd)
• Increasing Mastery and Pleasure
• Discuss rationale for activity scheduling
• breaks cycle of hopelessness
• natural antidepressant effects
• in contact with others
• increase self-efficacy
• positive outcomes

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CBT Strategies for Symptom Control - Depression

• Adding Positives
• Select a healthy habit to improve
• Ex healthy eating
• Start one new behavior that gets them closer to
  goal
• Ex eat breakfast in morning
• Select one problematic behavior to stop
• Ex Stop eating late at night

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Decision-Making

• Decision Making and Thought Processes
• Schedule time at end of day to review the day
• At least 1 hour before bedtime
• Not in bed
• Review the day and take notes on events that were
  troublesome or require more thought
• Things to do the next day
• Conversations
• Disappointments, worries
• For each item, note what needs to be done to
  rectify issue
• At bedtime, instead of ruminating, remind self
  that day has already been reviewed

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Decision-Making

• Decision Making using Advantages/Disadvantages
• Provides structure
• Can compare choices relative to one another
• Consider maximizing advantages of each choice
  while minimizing disadvantages

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Problem-Solving

• Problem identification and definition
• State problem as clearly as possible
• Generation of potential solutions
• List all possible solutions regardless of
  feasibility
• Eliminate less desirable or unreasonable choices
• Order in terms of preference
• Pros and cons
• Specify how and when solution is implemented

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Problem-Solving

• Implement Solution
• Implement as planned
• Evaluate effectiveness
• Decide whether a revision is needed or a new plan
  to address problem better
• Or return to step 2 and select new solution
• Ask questions to facilitate problem definition

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Reducing Stress

• Acute Stress Management
• Inquire about past coping methods
• YOU have faith in their ability to cope
• Relaxation training
• Stress Control and Problem Solving
• Cues to stress
• Internal and external
• Physical
• Emotional shifts
• Input from others

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Reducing Stress

• Stress Control and Problem Solving (contd)
• Proactive Scheduled Assessment
• Ex scheduling times to address progress and
  problems with spouse every 3-6 months
• Predictable times of change and stress
• Stress Prevention
• Activity scheduling
• Track activities for a week, rank for pleasure
  and accomplishment
• Schedule activities high in these areas
• Important to know limits
• Lifestyle choices and limit setting

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Interpersonal and Social Rhythm Therapy

• Combines IPT for unipolar depression with
  behavioral strategies designed to regulate daily
  routines and psychoeducation to enhance treatment
  adherence.

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Initial Phase

• Psychiatric and medical history
• Events leading up to current and previous
  episodes
• Evidence of alterations or disruptions in routine
  or interpersonal interactions
• Interpersonal inventory
• Review of all important past and present
  relationships
• Life circumstances
• Quality of relationships
• Listen for omissions/disruptions

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Initial Phase

• Education on disorder
• Symptoms
• Medications
• Side effects, etc.
• Role of circadian rhythm and rhythm disruption in
  disorder
• Interpersonal and Social Rhythm Therapy, Frank et
  al. (2000)
• Social Rhythm Metric (SRM)
• Record daily activities
• How stimulating activities were
• Daily mood

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Intermediate Phase

• Social rhythm strategies
• Review first 3-4 weeks of SRMs to find rhythms
  that seem unstable
• Ex sleep patterns
• Encourage to work toward stabilization
• Make goals for recovery/regulating rhythms
• Graded
• Range from short-term, intermediate, long-term
• Also examine larger environmental stressors
• Learn to adapt to changes in routine
• At some point, patient will question the need for
  stability

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Intermediate Phase

• Interpersonal strategies
• Identify problem area (grief, interpersonal role
  disputes, role transition, interpersonal
  deficits)
• Address the problem area
• Attend to its role in promoting or disrupting
  social regularity
• Ex loss of a loved one causes a disruption in
  social routine
• Ex fights with spouse lead to less sleep

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Preventative Phase

• Decreases from weekly to monthly sessions
• Can last 2 or more years
• Continue evaluating what works best for patient
• Eliminate or change disruptive activities
• Seek a stable pattern
• Encouragement to address problems as they arise
• May require crisis sessions as symptoms or
  interpersonal dilemmas arise

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Termination

• Over 4-6 monthly sessions
• Review patient success
• Discuss potential vulnerabilities
• Identify strategies for management of
  interpersonal difficulties and symptom relapses
• Encouragement about ability to use strategies
  independently

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Efficacy of CBT

• Lam et al. (2000)
• 6 months, 12-20 sessions of CBT
• Superior to outpatient treatment in reducing
  episodes and coping with symptoms
• Fava, Bartolucci, Rafanelli, Mangelli (2001)
• CBT added to medication in patients with frequent
  relapses
• Decreased residual symptoms and increase in time
  to relapse
• Follow-up of patients at 2-9 years
• Of the 15 patients, only 5 experienced relapse
• Swartz, Frank, Kupfer (2006)
• Review of psychotherapies
• Effect sizes of 0.32 to 0.45 (highest of all
  psychotherapies)
• Cognitive strategies benefitted depressive
  symptoms
• Behavioral strategies ameliorated manic symptoms

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Efficacy of IPSRT

• Frank et al., 1997
• Compared traditional medication treatment to
  IPSRT
• 52 weeks
• The 18 in IPSRT showed greater stability in
  routines
• The 20 in medication only group showed no change
  in routines

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Efficacy of IPSRT

• Frank et al., 2005
• 175 participants in acute treatment, then
  maintenance treatment (2 years)
• ICM ICM
• ICM IPSRT
• IPSRT IPSRT
• IPSRT ICM
• All in addition to pharmacotherapy
• Those in IPSRT acute phase had longer intervals
  to relapse during 2-year follow-up, regardless of
  maintenance treatment
• Also associated with a greater change in
  stability of routine
• Treatment during acute phase has a protective
  effect against future episodes