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Psychotherapy For Bipolar Disorder

Psychotherapy For Bipolar Disorder. Brooke Tompkins. Overview. Bipolar Diagnoses History and Facts Etiology Cognitive-Behavior Therapy Interpersonal and Social Rhythm Therapy Empirical Support. DSM-IV Diagnoses. DSM-IV Manic Episode.

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Psychotherapy For Bipolar Disorder

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  1. 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

  4. 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

  5. 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

  6. 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

  7. 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.

  8. 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

  9. DSM-IV Cyclothymic Disorder • For at least 2 years • hypomanic symptoms • depressive symptoms • Not without symptoms for more than 2 months at a time.

  10. 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

  11. 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

  12. 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

  13. Etiology – “Diathesis-Stress” • Biological predisposition + stressful events + subjective perception (“cognitive triad”) • Negative life events predict bipolar depression • But…combined with a high behavioral activation system - triggers mania • Excessive focus on goal attainment stimulates manic episode

  14. 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

  15. 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

  16. 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!

  17. 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

  18. 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

  19. 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

  20. Differential effects of psychotherapies Swartz, Frank, & Kupfer, 2006

  21. 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!

  22. Cognitive –Behavior Therapy Focuses on the cycle of reactions to symptoms that impair functioning, cause psychosocial problems, and increase stress

  23. 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

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

  25. 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

  26. 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

  27. 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

  28. 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

  29. Managing Hypomanic/Manic Symptoms • Interventions (cont’d) • 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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 I’ll need something stronger. • When I get home late I’m too tired to go to the kitchen to take my pills.

  36. 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.

  37. 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 life’s 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

  38. 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.

  39. 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

  40. Advantages/Disadvantages Technique

  41. 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

  42. CBT for Symptom Control – Manic & Depressive • Sleep Enhancement • Be consistent • It’s a nighttime thing • Keep your bed a place for sleep • Get comfortable • Gear down for the night • Avoid stimulants that might keep you awake • Don’t do: • Caffeine • Internet • TV and books • Chores • Exercise

  43. 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.

  44. 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

  45. CBT Strategies for Symptom Control - Depression • Goal: Increase behavior (cont’d) • 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

  46. 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

  47. 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

  48. 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

  49. 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

  50. 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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