lecture 9 Flashcards
Self-reported History of Hypomanic Symptoms in a Student Population
Mood Disorder Questionnaire is a self-report inventory that screens for a lifetime history of (hypo)manic experiences
Study sample (n = 167 first-year psychology undergraduate students)
Questions that map onto manic-type symptoms – more ppts had experiences manic symptoms – high in university students
Characterisations of mood episodes in bipolar disorder
The mood episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
The disturbance in mood and change in functioning is observable by others
Symptoms of Major Depression
At least 2 weeks of:
Depressed mood, most of the day, nearly every day
AND/OR
Markedly diminished interest or pleasure
Plus at least 3:
Significant change in appetite or weight
Insomnia or hypersomnia
Psychomotor agitation / retardation
Fatigue or loss of energy
Feelings of worthlessness and/or inappropriate guilt
Diminished ability to think or concentrate
Recurrent thoughts of death, suicidal ideation,
suicide attempt, or a specific plan for committing suicide
time frame of mania/hypomania
Mania (at least 1 week )
Hypomania (at least 4 days) of: (can persist if functioning is relatively ok
symptoms of mania and hypomania
abnormally and persistently elevated, expansive or irritable mood
and abnormally & persistently increased activity or energy
Plus at 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 in goal-directed activity
Excessive involvement in pleasurable activities that may have high potential for painful consequences
what must mania lead to
Mania must lead to marked impairment in social or occupational functioning,(e.g., during period, relationship broken down) hospitalisation, or psychosis
unipolar deperssion, bipolar 1, bipolar 11, bipolar 1- unipolar insomnia
Unipolar: major depressive episode only,
Bipolar type 1 – (only requires mania) mania, depression, hypomania
Bipolar 2 – depression and hypomania
Bipolar 1 – unipolar mania : just mania
Predictors of Relapse
Stressful interpersonal life events (Hammen et al., 1992)
High ‘Expressed Emotion’ (hostility, overprotectiveness, criticism) in family members (Miklowitz et al., 1988)
Disrupted social rhythm events (Malkoff-Schwartz et al., 1998) including sleep changes
Goal-attainment Events (Johnson et al., 2000) *manic symptoms and not depression e.g., starting a new job
Cyclothymia
For at least 2 years:
numerous periods of hypomanic symptoms not meeting threshold for hypomanic episodes
Numerous periods of depressed mood / loss of interest that do not meet depression
The symptoms cause clinically significant distress or impairment in: Social & Occupational
Other Specified Bipolar Disorder
Short-duration hypomanic like episodes (2-3 days) and major depressive episodes
Hypomanic-like episodes with insufficient symptoms and major depressive episodes
Hypomanic episodes without prior major depressive episode(s)
Short-duration cyclothymia
Short-duration manic-like episodes
Unable to determine whether bipolar or related disorder is primary
Bipolar At Risk (BAR) Criteria
Early detection of BD has focused on familial risk & identification of state-trait factors
Standardised Bipolar At Risk (BAR) criteria developed by Bechdolf & colleagues (2010):
Youth (15-25) experiencing:
Short duration high mood
Short duration high & low mood
First degree relative with BD plus low mood
BAR criteria has predictive validity, can be reliably assessed in an NHS context, & holds clinical utility
Bipolar disorder:
Importance of early identification
Bipolar disorder affects 1-3% of the population
Average duration of untreated illness (DUI) is 6- 10 years, or longer for onset in adolescence
Longer DUI is associated with more mood episodes & higher risks of suicide
Economic impact of Bipolar Disorder in the UK is projected to be £8.2 billion by 2026
biological underpinniongs bipolar
High heritability (Kieseppa et al., 2004)
Separate heritability of mania & depression (McGuffin et al., 2003)
Genes for mania may involve reward pathways, i.e. dopamine function
‘Resistance’ to Bipolar Disorder
12 individuals aged 30+, most with a history of diagnosable hypomanic episodes
Never sought treatment/No history of clinical depression/No diagnosis of bipolar disorder
Key findings:
High levels of functioning
Lower levels of catastrophising about changes in internal states
Reported ‘awareness’ of behaviour and social impact when feeling high
= psychological underpinnings
NICE Guidelines - primary care
Primary Care
Review treatment & care, including medication (e.g. antidepressant medication)
Offer choice of an evidence-based psychological intervention developed for BD (Cognitive Behavioural Therapy, Interpersonal Therapy, or Behavioural Couples Therapy)
Nice secondary care
Secondary Care (for deterioration in depressive symptoms, signs of hypomania, or mania (refer urgently)
Pharmacological interventions:
If mania or hypomania develops & person is taking antidepressant, consider stopping the antidepressant and offer an antipsychotic
Offer evidence-based psychological intervention
Treatments for Bipolar Disorder
Medication
Typically mood stabilisers (e.g. lithium) but also anti-depressants, and ant- psychotics
High relapse rates despite adequate medication -> comes with side effects as well
Psychological Treatments:
Relapse prevention or psychoeducation -> help them recognise differences in mood changes etc
Family Focused Therapy (Miklowitz et al., 1988)
Cognitive Behavioural Therapy (Lam et al., 2003)
psychological relpase prevention (provide, identify and work)
Provide: Provide information about bipolar disorder and how people with bipolar disorder learn to cope better
identify: Identify warning signs – also called ‘prodromes’ or ‘relapse signature’
Quantified and grounded in personal experience
work: Work collaboratively to identify effective coping strategies, e.g. relax, postpone behaviour, get feedback from family members
Efficacy of Relapse Prevention
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
Family Focused Therapy (FFT)
work: Work with families or groups of families
Provide: Provide psychoeducation to improve their understanding of bipolar – non-blaming
identify: Identify hostility, criticism and overprotectiveness & help build up more collaborative, positive communication
Efficacy of Family Focused Therapy (FFT)
Miklowitz et al. (2003)
Intervention:
21 sessions of family-focused psychoeducation and behavioural intervention vs crisis management
Results:
Reduced relapse rates and mood symptoms over 2 years
Rea et al. (2003)
Compared FFT to individual psychoeducation
Results:
lower rates of rehospitalisation
Cognitive Behavioural Therapy (CBT)
Develop problem list with client – develop formulation to understand mood experiences and how they can make sense of the experiences
During depression, identify ‘negative automatic thoughts’ & challenge; activity scheduling
During hypomania, identify coping strategies e.g., behavioural experiments
During remission, engage in relapse prevention
May develop a personalised formulation of client’s ‘schemas’ – problematic personal rules & test with behavioural experiments
Efficacy of CBT +STEP trial
Lam et al., (2003, 2005)
Intervention: 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
An Integrative Cognitive Model - mood swings
Mood swings are a consequence of multiple, conflicted, extreme, personal appraisals of changes in internal state
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
Leads to internal struggle trying to exert extreme control over internal states
An Integrative Cognitive Model of Bipolar Disorder IMAGE
Hypomanic and Positive Predictions Inventory
Social Self Criticism
Increasing Activation To Avoid Failure;
Success Activation & Triumph Over Fear;
Loss of Control;
Grandiose Appraisals of Ideation;
Regaining Autonomy; i
