Psychotherapy For Bipolar DisorderBrooke Tompkins

OverviewBipolar DiagnosesHistory and FactsEtiologyCognitive-Behavior TherapyInterpersonal and Social Rhythm TherapyEmpirical Support

DSM-IV Diagnoses

DSM-IV Manic EpisodeAbnormally 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-esteemdecreased need for sleep pressured speechflight of ideas or racing thoughtsdistractibility increase in goal-directed activityincreased involvement in pleasurable activities with a high potential for negative consequences

DSM-IV Major Depressive EpisodeFive (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 activitiessignificant weight loss or weight gaininsomnia or hypersomniapsychomotor agitation or retardationfatigue or loss of energyfeelings of worthlessnessdiminished ability to think or concentratesuicidal ideation

DSM-IV Mixed EpisodeSymptoms of a Manic Episode and a Major Depressive Episode nearly every day during at least a 1-week period.cause marked impairment

DSM-IV Hypomanic EpisodeElevated, 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.

DSM-IV Bipolar DisorderBipolar Disorder IAt least one manic or mixed episode (lasting for at least a week) within his or her lifetime. A depressive episode is not a diagnostic criteriaBipolar Disorder IIAt least one episode of hypomania at least one episode of depression Rapid Cycling 4 or more episodes in a yearBipolar NOS

DSM-IV Cyclothymic DisorderFor at least 2 yearshypomanic symptoms depressive symptoms Not without symptoms for more than 2 months at a time.

Prevalence and ComorbidityLifetime prevalence:0.8-1.6%Current point prevalence 18+ (NIMH) = 2.6%Median age of onset:Late adolescence, early 20sRate among adolescents is increasing (estimate of 1%)Comorbidities50% with alcohol or substance abuse disorders60% with anxiety disorders (Panic Disorder & Social Phobia)33-50% with personality disordersComorbidity is the rule rather than the exceptionAssociated with poorer course over time

Diagnostic IssuesOne-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 symptomsUp to 75% do not adhere to medication regimens

Etiology - Biological BasisHeritability as high as 80%First-degree relatives10% chance of bipolar disorder and unipolar depressionPolygenicInvolves a combination of several genesNew research - genetic vulnerability traits How?Dysregulation of neurotransmittersDifficulties in maintaining homeostasisSymptoms likely under neurobiological stressors (i.e., sleep deprivation)Different brain activity

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 maniaExcessive focus on goal attainment stimulates manic episode

Etiology - Circadian DysregulationBiological RhythmsSeasonal peaks SuicideSleep 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

Then and NowMost biological of severe psychiatric disordersPreviously thought amenable only to pharmacotherapyPsychoanalysis not effective1980sImproving pharmacological treatmentsImportant challenge treating chronic subacute depressive symptomsBeginning of research on psychotherapy

PharmacotherapyFirst line of treatmentStrongest support:Lithium (1949) recommended by APA Practice Guidelines report side effects, leads to discontinuation and hospitalizationMood stabilizers are less effective in reducing depressive symptomsMood stabilizers + antidepressants + antipsychoticsPsychotherapy as adjunct to pharmacotherapyKnow about medications!

Why Psychotherapy?Provide psychoeducation regarding symptomsPromote adherence with medication regimensAddress comorbid conditionsAmeliorate stigma and self-esteem consequencesEnhance social and occupational functioning and adjustmentReduce risk of suicideIdentify psychosocial triggers that increase the risk for relapseEvidence suggests that psychosocial treatments both reduce and prevent symptoms

Current Treatment GuidelinesAmerican Psychiatric Association, 2002Initiating mood stabilizing treatmentAdd one or more of the following:Specific psychotherapyAntidepressant medicationAPA Practice Guidelines

Supported Types of PsychotherapyInterpersonal and Social Rhythm Therapy (IPSRT)Cognitive-Behavior Therapy (CBT)Group or Individual PsychoeducationFamily Therapy

All trials of psychotherapy as complementary to pharmacotherapy (Swartz, Frank, & Kupfer, 2006)Possible phase-specific treatments

Differential effects of psychotherapiesSwartz, Frank, & Kupfer, 2006

Assessment of SymptomsSelf-Report Mood Disorders Questionnaire (Hirschfield, 2002)Clinical EvaluationSCID-IV.61-.64 reliability.76-.78 reliability when used with medical recordsAssessment of Symptom SeverityInventory 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 complianceAssess for suicide!

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

Cognitive Behavior Therapy

Cognitive-Behavioral ProcessPsychoeducationReactive Symptom Management Symptom Monitoring/Develop Early Warning SystemAdherence to TreatmentsSymptom Control (CBT and cognitive strategies)Reducing Stress

Generally around 12-20 sessions

Every SessionCollaborative agenda settingMood and medication assessmentReview homeworkSetting goals and priorities for sessionAssigning new homeworkFinal summary and feedback

PsychoeducationExplain disorder and role of cognition BD runs in familiesInvolves biochemical problems that can cause symptoms such as anger, impulsivity, depression, suicidality, exuberance, hypersexuality, and a false sense of invinciblityDiathesis-stress disorder - biological problem interacts with stress Can be dangerous to health, relationships, occupational success, etc.Much due to cognitive triadExplain negative explanatory styleCan be treated with both medication and psychotherapy

PsychoeducationExplain purpose of CBT treatmentsLearn to adopt constructive outlook on lifeProblem-solvingImprove quality of lifeEase of medication adherence Less likelihood of relapseIntroduce importance of homework Can assign reading materials for homeworkFinding Peace of Mind: Treatment Strategies for Depression and Bipolar DisorderBipolar Disorder

PsychoeducationKnowledge of medication and adherenceWhy medication is usedSide effectsMood stabilizing vs. antidepressant Expected outcome Long-term issues with managementWhy psychotherapy is needed in additionIdentify issues to discuss with physiciansProvide readings

Managing Hypomanic/Manic SymptomsRecognize warning signsInterventions and Rules:Medical solutions firstTwo-person feedback rule for great ideasLimit cash paymentsTo counteract impulsivity:Give car keys or credit cards to someone to keepRules about staying out late or giving out phone #Avoid alcohol and substance use minimize stimulation48-hours before acting rule* Treatment Contract

Managing Hypomanic/Manic SymptomsInterventions (contd)Imagery about worst-case scenariosRelaxation techniquesDiaphragmatic breathingPMRAddress 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

Symptom MonitoringIdentify how day-to-day experiences are related to symptoms of bipolar disorderAsk how illness has affected their lives and home environment Complete Symptom Summary WorksheetList of symptomsCircle what they experience in episodeCircle what they experience when normalHomework: Provide copies for patient to add symptoms throughout the week Teach patient to monitor key symptoms, such as changes in moodReview Mood Graph in session, complete for yesterday and todayHomework: Keep mood graphs.

Remember to always address homework at beginning of the next session

Development of Early Warning SystemComplete Life ChartReference line that represents a normal/euthymic stateDraw episodes of mania, depression, and mixed states on timelineDraw first episode together, they complete the restCan consult with family members, medical records, etc.Include types and dates of received treatment

Development of Early Warning SystemDevelop early warning systemDistinguish between normal and abnormal mood shiftsUsing Symptom Summary Worksheet and Life ChartMake detailed descriptions of patient in normal and episodic statesDescriptions used by patient, family members, can call therapist and review*use mood graphs

Treatment AdherenceIntroduce CBT model of adherenceNoncompliance is the norm, not the exceptionIllness interferes with adherenceNew conceptualization of adherence:Waxes and wanes over timeDifficulties from family, differing opinions, anger at some medications not working, etc.Strategies to reform opinion on illness, medications, and necessity of treatment

Compliance ContractsAssessment and GoalsReview dosing schedulesReview appointment plans Goals for homework assignmentsIdentify ObstaclesIntrapersonalTreatmentSocial systemInterpersonalCognitive Make plan for overcoming obstacles Ask about past successful strategiesMake a planPeriodically review and modify if necessary

Example Compliance ContractStep 1: Treatment PlanI, [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 ObstaclesI 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.

Example Compliance ContractStep 3: Plan for reducing obstaclesTo 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.

CBT Strategies for Symptom Control - ManicGoal: Testing Reality of Thoughts and BeliefsDiscuss typical hypomanic cognitive errorsoverreliance on luckunderestimating risk of dangeroverestimating capabilitiesdisqualifying negative, minimization of lifes problemsovervaluing immediate gratificationmisinterpreting intentions of others Discuss automatic thoughts and distorted cognitionsIf difficult to identify, describe general impressions and images until they can identify beliefs, themes, concerns Use Automatic Thought Records

CBT Strategies for Symptom Control - ManicAlert them to the impact the thought has on their mood stateUse behavioral experiments to test thoughtConsult with trusted othersExamine evidenceList evidence for/againstAlternative explanationsCognitive restructuring to evaluate thoughts

Homework: Keeping Automatic Thought Records.

CBT Strategies for Symptom Control - ManicGoal: Modifying Behavioral SymptomsNegative ImageryActivity Scheduling A and B listsPlan activities ahead of timeCan make a Daily Activity ScheduleIncreasing sitting and listeningSit when they notice they are speaking or moving rapidly in social situations interrupts acceleration of motor activityFocus on listening to others use self-statement prompts if neededPay attention. Listen to [name of person].Advantages/disadvantages technique

Advantages/Disadvantages Technique

CBT Strategies for Symptom Control - ManicStimulus ControlKnowing what activities to avoidAlcohol or other substancesUnsupervised spending of large amounts of moneyDaredevil hobbiesExaggerated generosity or friendliness with strangersActivities using a lethal weaponConsulting with othersFeedback

CBT for Symptom Control Manic & DepressiveSleep EnhancementBe consistentIts a nighttime thingKeep your bed a place for sleepGet comfortableGear down for the nightAvoid stimulants that might keep you awake Dont do:CaffeineInternetTV and booksChoresExercise

CBT Strategies for Symptom Control - DepressionGoal: Testing reality of negative thoughtsIdentification of Negative Automatic ThoughtsAutomatic Thought RecordEvidence for/evidence against techniqueAlternative ExplanationsPatient chooses explanation that seems most likelyReframe thoughts of suicideHave them write down reasons to liveHomework: Keep Automatic Thought Records.

CBT Strategies for Symptom Control - DepressionGoal: Increase behaviorDiscuss behavioral aspects of depressionNormalize feeling overwhelmed and overloadedHow have they coped with it in the past?Graded Task AssignmentList all tasks that require attentionDivide tasks into smaller stepsDevise plan to guide patient from one step to the nextA and B lists to help choose important tasks

CBT Strategies for Symptom Control - DepressionGoal: Increase behavior (contd)Increasing Mastery and Pleasure Discuss rationale for activity scheduling:breaks cycle of hopelessnessnatural antidepressant effectsin contact with othersincrease self-efficacypositive outcomes

CBT Strategies for Symptom Control - DepressionAdding PositivesSelect a healthy habit to improveEx: healthy eatingStart one new behavior that gets them closer to goalEx: eat breakfast in morningSelect one problematic behavior to stopEx: Stop eating late at night

Decision-MakingDecision Making and Thought ProcessesSchedule time at end of day to review the dayAt least 1 hour before bedtimeNot in bedReview the day and take notes on events that were troublesome or require more thoughtThings to do the next dayConversations Disappointments, worriesFor each item, note what needs to be done to rectify issueAt bedtime, instead of ruminating, remind self that day has already been reviewed

Decision-MakingDecision Making using Advantages/DisadvantagesProvides structureCan compare choices relative to one anotherConsider maximizing advantages of each choice while minimizing disadvantages

Problem-Solving Problem identification and definitionState problem as clearly as possibleGeneration of potential solutionsList all possible solutions regardless of feasibilityEliminate less desirable or unreasonable choicesOrder in terms of preferencePros and consSpecify how and when solution is implemented

Problem-SolvingImplement SolutionImplement as plannedEvaluate effectivenessDecide whether a revision is needed or a new plan to address problem betterOr return to step #2 and select new solution Ask questions to facilitate problem definition

Reducing StressAcute Stress ManagementInquire about past coping methods YOU have faith in their ability to copeRelaxation trainingStress Control and Problem SolvingCues to stress Internal and externalPhysicalEmotional shiftsInput from others

Reducing StressStress Control and Problem Solving (contd)Proactive Scheduled AssessmentEx: scheduling times to address progress and problems with spouse every 3-6 monthsPredictable times of change and stressStress PreventionActivity schedulingTrack activities for a week, rank for pleasure and accomplishmentSchedule activities high in these areasImportant to know limits Lifestyle choices and limit setting

Combines IPT for unipolar depression with behavioral strategies designed to regulate daily routines and psychoeducation to enhance treatment adherence. Interpersonal and Social Rhythm Therapy

Initial PhasePsychiatric and medical historyEvents leading up to current and previous episodesEvidence of alterations or disruptions in routine or interpersonal interactionsInterpersonal inventoryReview of all important past and present relationshipsLife circumstancesQuality of relationshipsListen for omissions/disruptions

Initial PhaseEducation on disorderSymptomsMedicationsSide effects, etc.Role of circadian rhythm and rhythm disruption in disorderInterpersonal and Social Rhythm Therapy, Frank et al. (2000)Social Rhythm Metric (SRM)Record daily activitiesHow stimulating activities wereDaily mood

Intermediate PhaseSocial rhythm strategiesReview first 3-4 weeks of SRMs to find rhythms that seem unstableEx: sleep patternsEncourage to work toward stabilizationMake goals for recovery/regulating rhythmsGradedRange from short-term, intermediate, long-termAlso examine larger environmental stressorsLearn to adapt to changes in routineAt some point, patient will question the need for stability

Intermediate PhaseInterpersonal strategiesIdentify problem area (grief, interpersonal role disputes, role transition, interpersonal deficits)Address the problem areaAttend to its role in promoting or disrupting social regularityEx: loss of a loved one causes a disruption in social routineEx: fights with spouse lead to less sleep

Preventative PhaseDecreases from weekly to monthly sessionsCan last 2 or more yearsContinue evaluating what works best for patientEliminate or change disruptive activities Seek a stable patternEncouragement to address problems as they ariseMay require crisis sessions as symptoms or interpersonal dilemmas arise

TerminationOver 4-6 monthly sessionsReview patient successDiscuss potential vulnerabilitiesIdentify strategies for management of interpersonal difficulties and symptom relapsesEncouragement about ability to use strategies independently

Efficacy of CBTLam et al. (2000)6 months, 12-20 sessions of CBTSuperior to outpatient treatment in reducing episodes and coping with symptomsFava, Bartolucci, Rafanelli, & Mangelli (2001)CBT added to medication in patients with frequent relapsesDecreased residual symptoms and increase in time to relapseFollow-up of patients at 2-9 yearsOf the 15 patients, only 5 experienced relapseSwartz, Frank, & Kupfer (2006)Review of psychotherapiesEffect sizes of 0.32 to 0.45 (highest of all psychotherapies)Cognitive strategies benefitted depressive symptomsBehavioral strategies ameliorated manic symptoms

Efficacy of IPSRTFrank et al., 1997Compared traditional medication treatment to IPSRT52 weeksThe 18 in IPSRT showed greater stability in routinesThe 20 in medication only group showed no change in routines

Efficacy of IPSRTFrank et al., 2005175 participants in acute treatment, then maintenance treatment (2 years)ICM + ICMICM + IPSRTIPSRT + IPSRTIPSRT + ICMAll in addition to pharmacotherapyThose 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