bipolar disorder Flashcards
what are the symptoms of mania
At least one week of persistently euphoric, expansive or irritable mood P
lus at least three or more of:
• Inflated self esteem / grandiosity
• Decreased need for sleep
• More talkative than usual, pressure of speech
• Flight of ideas, thoughts racing
• Distractibility
• Increased goal-directed activity
• Excessive involvement in pleasurable activities that may have high potential for painful consequences
Must lead to marked impairment or psychosis
how long is hypomania for
(Hypomania >4 days; no impairment)
more than 4 days
what does mania require to be a clinical problem
‘Mania’ requires:
– Euphoric or irritable mood plus 3 of the others
– One week or more of symptoms
– Marked impairment, hospitalisation or psychosis
what does hypomania require to be a clinical problem
– Euphoric or irritable mood plus 3 of the others
– 4 or more days of symptoms
– No necessary impairment but not ‘normal self’
what is unipolar depression
at least one episode of depression in their lifetime
neve had hypomania or mania
bipolar 1
at least one episode of mania and one episode of depression
bipolar 2
at least one episode of depression and one of hypomania
bipolar 1 - unipolar mania
at least one episode of mania
what are the associated symptoms of mania
- Symptoms during mania also include dysphoria, anxiety, panic and aggression (e.g Cassidy et al., 1998)
• Symptoms of depression typical even during remission (Judd et al., 2002)
• High levels (>50%) of comorbid disorders: anxiety, personality, substance abuse
• Studies show 2x UP rate of certain anxiety disorders (OCD – Chen & Dilsaver, 1995; panic & GAD – Simon et
al., 2003)
what are the biological factors of mania
Heritability high – (Kieseppa et al., 2004)
more likely to have it if have first degree relative who has it
• Separate heritability of mania & depression (McGuffin et al., 2003)
• Genes for mania may involve reward pathways, i.e. dopamine function
highs - reward pathwasy
lows- neuroticism
‘resistance’ to bipolar disorder
High levels of functioning
– Lower levels of catastrophising about changes in internal states
– Reported ‘awareness’ of behaviour and social impact when feeling high
what are the predictors of relapse
- Stressful interpersonal life events (Hammen et al., 1992) M&D
- High ‘Expressed Emotion’ (hostility, overprotectiveness, criticism) in family members (Miklowitz et al., 1988) M&D
- Disrupted social rhythm events (Malkoff-Schwartz et al., 1998) – Mania not D - going outside normal sleep wake patterns
- Goal-attainment Events (Johnson et al., 2000) – Manic symptoms not D - achievingthings
important issues predicting relapse in bipolar
- Poor compliance with medication – normative; often ineffective; side effects
- Poor acceptance of ‘illness’ - normative
- Poor recognition; delays in diagnosis
- Ambivalent views of hypomanic symptoms
- Stigmatisation
- Stress on family members
- Interpersonal processes during therapy - therapists have to be malleable to change in mood
what is the treatment for BP - medication
• Medication
– Typically mood stabilisers (e.g. lithium) but also anti- depressants, ant-psychotics and anxiolytics
– large majority of treated people with BP
– high relapse rates despite adequate medication (Solomon et al., 1995) – c.60% in 2 years
what is the psychological treatment for BP
Psychological Treatments (usually in addition to med):
– Relapse prevention or psychoeducation – effective (Colom et al., 2003; Perry et al., 1999)
– Family Focused Therapy (Miklowitz et al., 1988)
– Cognitive Behavioural Therapy (Lam et al., 2003)
what is psychoeducation/ relapse prevention
Provide information about bipolar disorder and how people with BP learn to cope better
• Identify warning signs – also called ‘prodromes’ or ‘relapse signature’
– Changes in thoughts, feelings, behaviours
– Quantified and grounded in personal experience
– Judge early, middle and late strategies
• Work collaboratively to identify effective coping strategies, e.g. relax, postpone behaviour, get feedback from family members
does relapse prevention work
Perry et al. (1999)
– Intervention: 7-12 sessions of individual relapse prevention vs. treatment as usual – Results: over 18 months, longer time to relapse with mania but no effects on time to relapse with depression
• Colom et al. (2003)
– Intervention: 21 sessions of group psychoeducation versus treatment as usual – Results: Reduced rates of relapse of mania and depression over 2 years
what is FFT
Family Focused Therapy
• Work with families or groups of families
• Provide psychoeducation to improve their understanding of BP – non-blaming
• Identify hostility, criticism and overprotectiveness & help build up more collaborative, positive communication
efficacy of FFT
Miklowitz et al., 2003
– 21 sessions of family-focused psychoeducation and behavioural intervention vs crisis management
– Reduced relapse rates and mood symptoms over 2 years
• Rea et al. 2003
– Compared FFT to individual psychoeducation
– lower rates of rehospitalisation
what happens in CBT
- Develop problem list with client
- During depression, identify ‘negative automatic thoughts’ & challenge; activity scheduling
- During hypomania, identify coping strategies
- During remission, engage in relapse prevention
• May develop a personalised formulation of client’s ‘schemas’ – problematic personal rules &
test with behavioural experiments
• E.g. ‘I must be a complete success or my life is worthless’ – experiment with ‘less than perfect’
work
efficacy of CBT
• Lam et al., 2003, 2005
– Groups: c.20 sessions Individual CBT vs treatment as usual
– Results: reduced symptoms of depression, longer time to relapse over 2 years, improved functioning
• STEP trial – Systematic Treatment Enhancement Programme (Miklowitz et al., 2007)
– 15 sites across USA
– Equal efficacy of 30 sessions of FFT, interpersonal therapy and CBT vs. minimal care – Intensive psychological therapies are all effective in community settings
• But effect sizes are modest, and focus is on prevention of relapse rather than current symptoms and recovery
what are mood swings according to the integrative cognitive model
Mood swings are a consequence of multiple, conflicted, extreme, personal appraisals of changes in internal state
what are examples of mood swings
– feelings of high energy = imminent success
– vs. feelings of high energy = mental breakdown
– Feelings of low energy = safe, relaxing
– vs. Feelings of low energy = failure, boring
what do mood swings lead to
leads to internal struggle trying to exert extreme control over internal states rather than active successful ways of pursuing goals
what is the integrative cognitive model of bipolar disorder
triggering event change in internal state appriased as having extreme personal meaning beliefs about self world and others life experiences ascent behaviours descent behaviours
probability of bipolar as a function of positive and negative appraisals
high negative and positive appraisals
what does TEAMS stand for
think effectively about mood swings
what does TEAMS involve
– Focused on present problems, e.g. depression,anxiety, irritability, high mood
– Working through the principle of safety – engagement
– experience – formulation – change
– Identify core personal goals and values
– Explore and monitor internal states on a continuum and identify their various appraisals
– Facilitate reappraisals and broaden ‘bandwidth’ in internal states that are tolerated and acceptable
– Form a flexible ‘healthy self’ that achieves goals that are less dependent on internal states
what happens in goal identification
Goal Identification
• Expressing needs is a major factor in recovery
• Questions to elicit goals e.g. “How would you like things to be?”
• Identifying long-term goals
• e.g. “What makes this particularly important for you?”
• Making things concrete
• e.g. “What would this look like?”
what happens in exploring internal states
Exploring Internal States
• Feelings are a normal and important part of life
• Put yourself in their shoes e.g. “What does that feel like right now?”
• Explore metaphors
• e.g. “When you say a ‘buzzy’ feeling, what makes it like this?”
• Ground in body and mind
• e.g. “What does it feel like in your head when you are buzzy?”
• e.g. “What’s do you notice in your body?”
what happens when plotting a continuum
- Thinking in ‘shades of grey’ is more effective that black & white
- Identify extremes
- e.g. “What does depression involve for you at its worst?”
- e.g. “Could you describe to me your most extreme highs?”
- Describe ‘middle’ states
- e.g. “What kind of states do you have in the middle range?”
- Explore duration and control
what happens in pros and cons
Pros and Cons
• All moods have both advantages and drawbacks
• Recognise both sides
e.g. “Can we talk about what you think of this state of mind?”
• Explore the negatives
• e.g. “What are the diffculties about being in this state?”
• Explore the positives
• e.g. “Are there any good things about being in this state?”
• Reflect
• e.g. “What do you make of the pros and cons we listed?”
• e.g. “Any more we might have missed?”
what is the metaphor for bipolar
icarus
what is the pyramid of therapy principles
safety engagement experiential processing awareness of formulation change and recovery
was there an effect of TEAMS
no effect of TEAM vs TAU in any measures
despite bulding model and being a strong predictor of mood swings when employed clincially - couldnt detect a large enough effect of therapy on symptoms
summary of BD
Bipolar disorder can have a huge impact on functioning
• Symptoms of BP are on a continuum with ‘normal’ experiences
• Several psychological treatments are effective
• Emerging evidence to support the Integrative Cognitive Model and TEAMS therapy
