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Bipolar Disorder


CBT & Diathesis Stress Model ... CBT-Four phase strategy ... Combines techniques from CBT and IPSRT-usually 6-10 sessions ... – PowerPoint PPT presentation

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Title: Bipolar Disorder

Bipolar Disorder
  • Kim Carter
  • Appalachian State University

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.

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

Prevalence Rates and Course
  • Bipolar I
  • Lifetime .4-1.6
  • in men and women
  • Menmanic episodes
  • Womendep episodes
  • Womenrapid cycling
  • Ave. age onset 20
  • Recurrent
  • 60-70 of manic episodes occur before or after a
    depressive episode

Prevalence Rates and Course
  • Bipolar II
  • Lifetime .5
  • May be more common in women than men
  • Menhypomanic than depressive episodes
  • Womendepressive than hypomanic episodes
  • Womenrapid cycling
  • 60-70of hypomanic episodes occur before or after
    a depressive episode
  • Interval between episodes decrease with age
  • Less data overall

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

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

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

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

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

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

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

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

List of Prognostic Indicators of Treatment
  • 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

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

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

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
  • 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

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

Major Issues that Impede Diagnosis and
Recognition of B.D.
  • Lack of reliable assessment tools for Bipolar
  • Misdiagnosed as unipolar depression
  • Children, adolescents and young adults are often
    diagnosed with ADHD
  • People often do not have clear cut, discrete mood
  • Mania if often unrecognized or considered
    irritability/ aggression
  • Psychotic features are often mistaken for
  • 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

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

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

SUICIDE RISK Must Be Continually Monitored
  • Suicide completion rates in patients with B.D.
  • 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

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

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

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
  • Limit access to weapons, cars, credit cards, bank
    accounts, etc.

Therapist Variables
  • The therapist has a large impact on treatment
  • 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

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

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.

Psychoeducation for family and
  • 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

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

Psychosocial Treatments are useful for Bipolar
Disorder by
  • Increasing medication compliance
  • Improving quality of life
  • Enhance coping mechanisms for stress

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

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

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

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

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

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

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
  • Reducing the harmful sense of stigma and shame

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

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
  • 4. Dealing with long term vulnerabilities-carefull
    y assessing past triggers allows the client to
    identify themes that may help in future relapse

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

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

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

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
  • Dialectical Behavior Treatment can be an
    effective group format for clients

  • 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
  • Consider crisis management and develop a plan

  • 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
  • Buaer, M. McBride, L. (1996). Structured Group
    Psychotherapy for Bipolar Disorder The Life
    Goals Program. New York Springer Publishing
  • 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
  • Newman, C., Leahy, R., Beck, A.,
    Reilly-Harrington, N. Gyulai, L. (2002).
    Bipolar Disorder A Cognitive Therapy Approach.
    Washington, D.C. American Psychological
  • Rivas-Vazquez, R., Johnson, S., Rey, G., Blais,
    M. Rivas-Vazquez, A. (2002). Current treatments
    for Bipolar Disorder  A review and update for
    psychologists. Professional Psychology Research
    and Practice, 33, 212-223.
  • Vieta, E. Colom, F. (2004). Psychological
    interventions in Bipolar Disorder From
  • wishful thinking to an evidence-based
    approach. Acta Psychiatrica Scandinavica,110,