Bipolar Disorder I

Kate Ueland

“Depression is a painfully slow, crashing death. Mania is the other extreme, a wild roller coaster run off its tracks, an eight ball of coke cut with speed. It's fun and it's frightening as hell. Some patients - bipolar type I - experience both extremes; other - bipolar type II - suffer depression almost exclusively. But the "mixed state," the mercurial churning of both high and low, is the most dangerous, the most deadly. Suicide too often results from the impulsive nature and physical speed of psychotic mania coupled with depression's paranoid self-loathing.”

- David Lovelace, Scattershot: My Bipolar Family

DSM Criteria

O The essential feature of a Bipolar I Disorder is the presence of at leastO one episode of mania; the patient may have experienced

mixed, hypomanic, and depressive episodes as well.

O The criteria for pediatric Bipolar Disorder are not defined, and adult criteria are typically used. Children and adolescents often present with a pattern of illness of very rapid, brief, recurring episodes and/or rapid fluctuations in mood and behavior, however pediatric diagnosis should be made with caution.

StatisticsO Seven out of 10 people with bipolar disorder

receive one misdiagnosis.O 30 %of people with untreated bipolar

disorder commit suicide.O Delayed diagnosis or misdiagnosis

contributes to 50 % of bipolar consumers abusing alcohol or drugs.

O An equal number of men and women develop this illness and it is found among all ages,

O races, ethnic groups and social classes.O Average length of time from onset of

symptoms to diagnosis is 10 years.O Bipolar disorder accounts for approximately

$7.6 billion in direct healthcare costs in the U.S.

O Lifetime costs per consumer range from $12,000 for a person with a single manic episode to more than $600,000 for those with multiple episodes.

The manifestation of Bipolar disorder

O The biopsychosocial model is the leading theory regarding the cause of Bipolar Disorder.

O biological vulnerabilities, such as carrying genes that make one more susceptible, it is known that depressed individuals are often significantly disturbed with regard to endocrine, immune, and neurotransmitter system functioning.

O psychological factors, such as a bias toward pessimistic thinking, which make one more vulnerable, deficits in coping skills, judgment problems, and impaired emotional intelligence

O social factors, such as trauma,, early separation, lack of social support, or harassment (bullying) can all contribute to vulnerability (Nemade, Reiss and Dombeck 2007)

O The stress-diathesis model is the leading theory about how Bipolar Disorder is triggered.

O Diathesis means vulnerability, and refers to things like genetic vulnerability.

O Stress means social and psychological stress which exceed our ability to cope and increase our chances of illness onset and subsequent mood episodes. (Nemade, Reiss and Dombeck 2007)

“It's difficult. I take a low dose of lithium nightly. I take an antidepressant for my darkness because prayer isn't enough. My therapist hears confession twice a month, my shrink delivers the host, and I can stand in the woods and see the world spark.”

- David Lovelace, Scattershot: My Bipolar Family

Signs and SymptomsMania or a manic episode include:Mood ChangesO A long period of feeling "high," or an overly

happy or outgoing moodO Extremely irritable mood, agitation, feeling

"jumpy" or "wired.“

Behavioral ChangesO Talking very fast, jumping from one idea to

another, having racing thoughtsO Being easily distractedO Increasing goal-directed activities, such as

taking on new projectsO Being restlessO Sleeping littleO Having an unrealistic belief in one's

abilitiesO Behaving impulsively and taking part in a

lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.

Depression or a depressive episode include:Mood Changes~ Along period of feeling worried or

empty~ Loss of interest in activities once

enjoyed, including sex.

Behavioral Changes~ Feeling tired or "slowed down“~ Having problems concentrating,

remembering, and making decisions

~ Being restless or irritable~ Changing eating, sleeping, or

other habits~ Thinking of death or suicide, or

attempting suicide.

Treatment Goals: Pharmacotherapy

O Bipolar is a lifelong disease that swings from manic to depressive episodes that vary in length and severity. Currently there is no cure for the disease and so treatment goals focus on managing the episodes with pharmaceutical drugs. Psychotherapy has shown to be very effective as an adjunct to pharmacotherapy.

O Three Phases of Drug Treatment:O Acute Phase - goal is to control the most severe symptoms of the manic, mixed or

depressive disorder (antipsychotic + mood stabilizer)O Stabilization Phase - goal is to help the patient fully recover from the acute phase

(antipsychotic + mood stabilizer)O Maintenance Phase – goal is to prevent recurrences and continue to treat residual

symptoms (antidepressant) (Barlow,2008).

O Medications: Mood Stabilizers: - Lithium carbonate, Anticonvulsants - Epakote, Lamictal, Antipsychotics - Seroquel and Risperdal Antidepressants - Selective serotonin reuptake inhibitors (SSRIs), Monoamine oxidase inhibitors (MAOIs) – although antidepressants are used they haven’t been found to be as effective as mood stabilizers.

Treatment Goals: Psychotherapy

O Patients who are treated for Bipolar Disorder exclusively with pharmacotherapy tend to have “breakout episodes”. Research has shown psychotherapy to help reduce the frequency of breakout episodes. It also helps patients with symptom management by providing a skill set to cope with stress triggers (e.g., life events and family tensions), augment social and occupational role functioning, and to keep patients on their medications (Barlow,2008).

O Psychotherapy Treatments:~ Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change

harmful or negative thought patterns and behaviors. The use of CBT group therapy as part of the pharmacological treatment have demonstrated that after treatment, participants presented fewer manic, depressive and anxiety symptoms and a reduction in the frequency and duration of mood change episodes (Thomaz da Costa,2010).

~ Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one (Miklowitz, Simoneau, George, et. al. 2000). This therapy also improves communication, problem-solving, enhanced lithium compliance, fewer relapses and a reduced rehospitalization rate (Huxley, Parikh, & Baldessarini, 2000).

Treatment Goals: Psychotherapy

~ Interpersonal and social rhythm therapy along with medications, combines the basic principles of interpersonal psychotherapy with behavioral techniques to help patients regularize their daily routines, improve their relationships with others and adhere to medication regimens. It modulates both biological and psychosocial factors to mitigate patients’ circadian and sleep–wake cycle vulnerabilities (Frank, 2000).

~ Psychoeducation teaches people with bipolar disorder about the illness and its treatment and is usually done from a CBT approach (Otto, Reilly-Harrington, Sachs 2003). This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers. (Miklowitz, Simoneau, George, et. al. 2000).

“I know the empathy borne of despair; I know the fluidity of thought, the expansive, even beautiful, mind that hypomania brings, and I know this is quicksilver and precious and often it's poison. There has always existed a sort of psychic butcher who works the scales of transcendence, who weighs out the bloody cost of true art..”

- David Lovelace, Scattershot: My Bipolar Family

Challenges~Diagnosis can be tricky or go undiagnosed and is

often misdiagnosed as unipolar depression.~People not adhering to their medications and having

relapses in either manic or depressive episodes. ~The distinction between bipolar disorder and Axis II

disorders is especially difficult~Reconciling with the idea that they have an illness.

This can be hard on both the patients and the family members.

(Barlow, 2008)

Discussion

O From the presentation what other challenges can you foresee as a health counselor either from a personal or a professional standpoint

O Which therapy focus resonates most with each of you?

References

O Barlow, D.H. (2008). Clinical Handbook of Psychological Disorders – A Step-By-Step Treatment Manual. New York: The Guilford Press. 421-462.

O Frank, E. (2000) Interpersonal and Social Rhythm Therapy: Managing the Chaos of Bipolar Disorder. Society of Biological Psychiatry,48,593–604.

O Huxley, N.A., Parikh, S.V., & Baldessarini, R.J. (2000). Effectiveness of Psychosocial Treatments in Bipolar Disorder: State of the Evidence. Harvard Rev Psychiatry, 8, 126–140.

O Miklowitz, D.J., Simoneau, T.L., George, E.L. et. al. (2000). Family-Focused Treatment of Bipolar Disorder: 1-Year Effects of a Psychoeducational Program in Conjunction with Pharmacotherapy. Society of Biological Psychiatry, 48, 582–592.

O National Institute of Health (2012). Bipolar Disorder. http://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml

O Nemade R. Reiss S. Dombeck M. (2007) Current Understandings of Major Depression - Biopsychosocial Model. http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=12997&cn=5

O Otto, M.W., Reilly-Harrington, N. & Sachs, G.S. (2003). Psychoeducational and cognitive-behavioral strategies in the

O management of bipolar disorder. Journal of Affective Disorders, 73, 171–181.O Thomaz da Costa, R. et. al. (2010) The effectiveness of cognitive behavioral group therapy in

treating bipolar disorder: a randomized controlled study International Journal of Nursing Studies, 47, 896–908