Bipolar Disorder
Kim Carter
Appalachian State University
What is Bipolar Disorder ?
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It is a spectrum of
affective episodes
including:
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Major depressive
episode
Manic episode
Mixed episode
Rapid cycling
Hypomanic episode
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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?
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Bipolar I
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1+ manic or mixed
episodes
May have other mood
episodes
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Bipolar II
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1 + major depressive
episodes AND
1 + hypomanic episodes
Never manic or mixed
episode
Prevalence Rates and Course
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Bipolar I
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Lifetime: .4-1.6%
= in men and women
Men>manic episodes
Women>dep episodes
Women>rapid cycling
Ave. age onset = 20
Recurrent
60-70% of manic episodes occur before or after a depressive
episode
Prevalence Rates and Course
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Bipolar II
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Lifetime: .5%
May be more common in women than men
Men>hypomanic than depressive episodes
Women>depressive than hypomanic episodes
Women>rapid cycling
60-70%of hypomanic episodes occur before or after a
depressive episode
Interval between episodes decrease with age
Less data overall
Cyclothymic Disorder
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Chronic fluctuating periods of hypomanic and
depressive symptoms for a 2 year period,
absence of symptoms < 2 months
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.
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Rapid cycling (days) between manic and
depressive symptoms
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Recurrent hypomanic episodes without
intercurrent depressive symptoms
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Hypomanic episodes, along with chronic
depressive symptoms, that are too infrequent to
qualify for a diagnosis
Etiological Factors
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Hereditary Factors
Biochemical Hypothesis
Stressful Life Events
Cognitive Styles as Vulnerabilities
Hereditary Factors
 1st degree relatives have significantly
higher rates
 Twin and adoption studies indicate
genetic vulnerability
 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 depressive
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 Outcome
1.
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6.
7.
8.
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 DisorderMajor Public Health Issue
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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:
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Bipolar vs. unipolar
ADHD
Schizophrenia
Substance abuse
Axis II
Substance Abuse and Bipolar
Disorder
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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
population
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
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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.
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Lack of reliable assessment tools for Bipolar Disorder
Misdiagnosed as unipolar depression
Children, adolescents and young adults are often diagnosed with
ADHD
People often do not have clear cut, discrete mood episodes
Mania if often unrecognized or considered irritability/
aggression
Psychotic features are often mistaken for Schizophrenia
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.
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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. 10-15%
– 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:
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PAI, MCMI
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
triggers
• Limit access to weapons, cars, credit
cards, bank accounts, etc.
Therapist Variables
• The therapist has a large impact on
treatment outcome
• 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 pressing
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 client
• 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 family
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 Interventions
Include individual, family and group
psychotherapies
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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
stress
Psychosocial Interventions
• Main goals continued:
• Identifying interpersonal difficulties commonly arising
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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
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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
rhythms
Interpersonal and
Social Rhythm Theory
• Two main goals-help clients recognize and
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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
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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
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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
interactions
Reducing the harmful sense of stigma and
shame
CBT-Four phase strategy
• 1. Psychoeducation
• 2. Introduce cognitive behavioral skills to cope
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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
techniques.
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 routines
• 4. Dealing with long term vulnerabilities-carefully
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–
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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 vulnerabilities
• Recognize negative life events as triggers
• Continued goal setting
Family and Couples Therapy
• Designed for problem solving and communication
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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
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have basically the same features:
Begins with psycho-education-usually 5 sessions
Combines techniques from CBT and IPSRTusually 6-10 sessions
Focus on relapse prevention, understanding
triggers
Dialectical Behavior Treatment can be an
effective group format for clients
Termination
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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
relapse
Consider crisis management and develop a plan
References
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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 Association.
Buaer, M. & McBride, L. (1996). Structured Group Psychotherapy for Bipolar Disorder: The Life Goals
Program. New York: Springer Publishing Company.
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
Press.
Newman, C., Leahy, R., Beck, A., Reilly-Harrington, N. & Gyulai, L. (2002). Bipolar Disorder: A
Cognitive Therapy Approach. Washington, D.C.: American Psychological Association.
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, 34-38.