Lecture 12 - Bipolar

Question 1

Bipolar - Description

Answer 1

• – experiences of extremely high moods and extremely low moods.
  
  • Manic episodes – abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy. Symptoms of inflated self-esteem and grandiosity, decreased need for sleep, more talkative than usual, flight of ideas or racing thoughts, distractibility, increase in goal-directed activity or psychomotor agitation, and excessive risk-taking behaviour (business, purchasing, sexual activity). Need 3+ symptoms for 1+ weeks, with either psychotic features or hospitalisations.
  • Hypomanic episodes – some symptoms for 4+ days, no need for hospitalisation or presence of psychosis. Needs to be a change in someone’s normal behaviour.
  • Depressive episodes – depressed mood, markedly decrease interest or sense of pleasure, significant weight or appetite change, sleep disturbances, psychomotor agitation or retardation, fatigue/loss of energy, feelings of worthlessness/guilt, poor concentration, suicidal ideation. 5+ symptoms, 2+ week period.
  • Prevalence – 1% for BP1, 0.4% for BD2 lifetime rates. Men and women equally. Onset of late adolescence and early adulthood. Often won’t get a diagnosis until 10 years after first symptoms – unless someone is experiencing a manic episode it often isn’t obvious, and will usually present with depression, since the manic episodes seem like a relief and not something to seek help for.

Question 2

Bipolar - Aetiology

Answer 2

• Diathesis-Stress Model – highly heritable (80% of cause). Biochemical imbalance (abnormal serotonin chemistry). Onset linked to stressful life events and disrupted circadian rhythms (also seasonal onsets – rapid increase in daylight). Risk factors – noncompliance with medication, maladaptive coping strategies, alcohol or drug use, disrupted sleep, irregular daily routines, interpersonal conflicts, stressful events.
• Interpersonal and Social Rhythm Therapy Approach – based on anecdotal evidence, and a treatment rather than a theory approach. Improving social support and relationships and re-establishing circadian and social rhythms.
• Behavioural Approach System Dysregulation Theory – behavioural approach system leads us to approach situations that could lead to rewards. Triggered by incentive cues and reward paradigms. Overactive system = symptoms of mania; underactive system = symptoms of depression. Weak BAS regulation means that the system is hyper-responsive to environmental stimuli and cues greatly influence level of activation. Expanded model – explains the origin of episodes and the appraisals that lead to the onset.
  
  • Origin of manic episodes – BAS scans the environment, seeing a reward cue. Higher levels of self-efficacy where the BAS sets off the manic episode with faster onset, more intense symptoms, and a slower recovery rate.
  • Origin of depressive episodes – BAS notices failures, and a further failure leads to lower self-efficacy and symptoms of depression.
  • Predictions – bipolar individual notices more opportunities and desires them more (BAS-relevant); creation of a greater number of BAS-relevant events due to extreme pre-event BAS states (mania); more extreme efficacy appraisal in both directions and a larger perceived domain of efficacy. Greater magnitude of all aspects of BAS response to BAS-relevant events (agitation or retardation), and dysregulated chronometry of BAS response (faster to peak, longer response).

Question 3

Bipolar - Assessment

Answer 3

• – if a client presents with depression, it is essential to ask about periods of elevated mood in order to differentially diagnose.
  
  • Mood Disorders Questionnaire (MDQ) – clinician administered screening tool – don’t distinguish between the episodes. Self-report. 13 yes/no items, with two more questions on clustering of symptoms and degree of dysfunction on a 4 point scale. Valid with acceptable sensitivity.
  • Black Dog Institute Bipolar Disorder Self-Assessment – experiences of depressive symptoms, mood cycles, and feelings of highs. Checklist of symptoms. 22-27 + depressive symptoms = possible diagnosis of BD.
  • Structured Clinical Interview for the DSMIV (SCID) – mostly widely used assessment. 1-2 hours to complete. Good psychometrics but does not reliably detect BDII.
  • Schedule for Affective Disorders and Schizophrenia (SADS) – 1-2 hours to complete. Symptoms, severity, and associated features. Most recent and broader past assessment. Good to excellent reliability for BDI but not reliable for diagnosing BDII.
  • Quality of Life Bipolar Disorder (QoL.BD) – 56 items, 5 minutes to administer. Baseline and change tracking. Good psychometrics.
  • Altman Self-Rating Scale for Mania (ASRM) – 5 minute scale. 5 items over the past week. Good psychometrics.
  • Young Mania Rating Scale (YMRS) – 15-20 minute interview. 2 days and observations during the interview. 11 items covering core manic symptoms. Good psychometrics, but gradiosity combined with other psychotic symptoms, and does not assess all DSM criteria.
  • Bech-Rafaelson Mania Rating Scale (MAS) – 11 items on a 5 point scale. Widely used in treatment and research. Excellent psychometrics, and reliably discriminates treatment and placebo groups.
  • Schedule for Affective Disorders and Schizophrenia Change (SADS-C) – depression and mania, assessing severity over the last week. 5 items on 6 point scale. Good psychometrics.

Question 4

Bipolar - Diagnosis

Answer 4

• Bipolar 1 – must have had at least one manic episode.
• Bipolar 2 – at least one hypomanic episode and one MDE. There has never been a manic episode. If a manic episode occurs BDI is diagnosed. Not a milder form of BDI – more depressive, and the mood fluctuations can be equally impairing.
• Comorbidity – BDI: 65-95% of BD, 70% have anxiety at some point, and over 50% have substance abuse disorders. 15x the risk of suicide. BDII: 60% of people have 3+ comorbidities, 14% lifetime eating disorders.
• Differential Diagnosis – easily mistaken for MDD or other BD. Substance abuse is common
• DSM-5 Changes – bipolar disorders separated from mood disorders – bridge between mood disorders and psychotic disorders. Added mood change and increase in activity/energy levels. With mixed features specifier.

Question 5

EBT - Bipolar

Answer 5

• – pharmacotherapy is the first line treatment for BD. Mood stabilisers (lithium and anticonvulsants, first line treatment for mania, depression, and maintenance). Antipsychotics (immediate stabilisation, whereas Lithium takes 1 week to come into effect). Adjunctives (SSRIs for depressive symptoms, BZDs for mania).
  
  • Lithium – first line treatment, mood stabiliser. Poorly understood how it works. Decreasing recurrence of mood episodes, and can work on acute mania, although antipsychotics are more effective in the short term and better tolerated. 30% of patients with good treatment adherence do not respond.
  • Medication Issues – low adherence rate, leading to risk during mania, high levels of suicidality, and relapse. 20-60% non-adherence in long term pharmacotherapy. 60% of those who experienced acute mania admitted non-adherence in the month preceding hospitalisation.
    
    • Side Effects – metabolic syndromes, cardiovascular disease, and Type II diabetes, due to lifestyle, lack of health resources, and neurobiological processes. Sedation, cognitive impairment, weight gain, toxicity, and teratogenic effects.
  • Psychotherapy – Lv2 evidence for CBT, Family Focused Therapy, Interpersonal and Social Rhythm Therapy, Psychoeducation, and Mindfulness Based Cognitive Therapy as adjuncts to medication.
  • STEP-BD – Systematic Therapy Enhancement Program for Bipolar Disorder. No differences in completion rates between CBT, FFT, IPSRT and Collaborative Care – intensive therapies are as acceptable. All intensive therapies had shorter recovery times and more time well compared to CC. All treatments included Psychoeducation, relapse prevention, and illness management training.
  • CBT – CBT + medication compared to medication only – combined had fewer acute episodes, fewer hospitalisations, less time in hospital, and better coping with prodromal mania. Lower depression scores at 6 month follow up.
    
    • Monitoring of mood – prodromal stages identified. Balanced Thinking Worksheet – extreme thoughts challenged, alternative views provided.
    • Monitoring of extreme ‘striving’ attitudes – BAS in/congruent thoughts triggering symptoms.
    • Psychoeducation about Diathesis Stress model.
    • Sleep hygiene to avoid triggering an episode
  • Family Focused Therapy – mood episodes are disasters for the family system. Expressed emotion measured – high levels lead to criticism, hostile, or dependent. FFT had fewer relapses with combined treatment than Individual therapy, less likely to be hospitalised. Psychoeducation à Communication Enhancement Training à Problem Solving. Need to integrate the experiences of mood episodes, accept the vulnerability to future episodes and a dependence on mood stabilisers, helping to distinguish between the client and their bipolar
  • Interpersonal and Social Rhythm Therapy – disturbed circadian rhythms can lead to symptoms. Social and personal demands that set the biological rhythms, and there are some disturbances which can interrupt these rhythms. Initial Phase (assessment and psychoeducation) à Intermediate Phase (establishing routines using the Social Rhythm Metric) à Preventative Phase à Termination Phase
  • Psychoeducation – intensive, structured treatment, addressing lifestyle regularity, illness awareness, detection of prodromal symptoms, and treatment compliance. Recurrence rates, triggering factors, medication, prodrome detection, emergency planning, symptom management, substance use and risks, maintaining routines (esp. circadian), healthy habits, stress management, suicide risk, stigma.
  • ALL PSYCHOTHERAPY – providing psychoeducation about the illness and prodromal symptoms; increasing acceptance and increasing adherence (side effects and ongoing treatment); building coping skills; consistency in circadian and social routines; interpersonal and family support; reducing substance misuse.

Question 6

Bipolar - Challenges

Answer 6

• Distinguishing between happiness and mania.
• Making up for lost time – mania supplementing the downtime from depression.
• Family support
• Stigma is huge
• Medication compliance – discussed above
• I still want to be me – don’t want them to be boring, just want them to avoid huge fluctuations. Avoiding extremes allows you to avoid the consequences.