Lecture 9, Bipolar Disorder

Question 1

How do we know if a disorder is ‘normal’?

Answer 1

There are subjective and objective ways to determine if the symptoms of a disorder are normal. Subjective ways include personal experiences or opinions of friends, while objective ways involve checking if the symptoms fall within a normal distribution, if people without the disorder experience them, if a person can function effectively despite experiencing the symptoms, and if they can be explained by normal cognitive functioning.

Question 2

Study on Self-reported History of Hypomanic Symptoms in a Student Population

Answer 2

Udachina and Mansell (2007) conducted a study on first-year psychology undergraduate students using the Mood Disorder Questionnaire. The questionnaire is a self-report inventory that screens for a lifetime of (hypo)manic experiences. The study sample consisted of 167 students.

Question 3

Characterisations of Mood Episodes in Bipolar Disorder

Answer 3

Mood episodes in bipolar disorder are characterized by an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Additionally, the disturbance in mood and change in functioning is observable by others.

Question 4

Symptoms of Major Depression

Answer 4

Symptoms of major depression include depressed mood most of the day, nearly every day for at least two weeks, along with markedly diminished interest or pleasure in all, or almost all, activities. At least three of the following symptoms must also be present: significant change in appetite or weight, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness and/or inappropriate guilt, diminished ability to think or concentrate, and recurrent thoughts of death, suicidal ideation, suicide attempt, or a specific plan to commit suicide.

Question 5

Symptoms of Mania and Hypomania

Answer 5

Mania and hypomania are characterized by an abnormally and persistently elevated, expansive or irritable mood, along with abnormally and persistently increased activity or energy. In mania, these symptoms must last for at least one week, while in hypomania, they must last for at least four days. Additionally, at least three of the following symptoms must be present: inflated self-esteem/grandiosity, decreased need of sleep, more talkative than usual/pressure of speech, flight of ideas/thoughts racing, distractibility, increased goal-directed activity, and excessive involvement in pleasurable activities that may have high potential for painful consequences. Mania must lead to marked impairment in social or occupational functioning, hospitalization or psychosis.

Question 6

Predictors of Relapse in Bipolar Disorder:

Answer 6

-> 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

Question 7

Cyclothymia:

Answer 7

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 or other important areas of functioning

Question 8

Other Specified Bipolar Disorder:

Answer 8

Different types: There is a lot of co-morbidity between mood disorders, trauma disorders and anxiety disorders
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 determined whether bipolar or related disorder is primary.
Other (describe)
Unspecified

Question 9

Bipolar At Risk (BAR) Criteria:

Answer 9

Early detection of BD has focused on familial risk and identification of state-trait factors.
Standardised BAR criteria developed by Bechdolf & colleagues (2010) – youth (15-25) experiencing short duration high mood; short duration high and low mood & first degree relative with BD plus low mood.
BAR criteria has predictive validity, can be reliably assessed in an NHS context, and holds clinical utility.

Question 10

What do we know about BD? Importance of early identification:

Answer 10

BD 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 and higher risks of suicide
Economic impact of BD in the UK is projected to be £8.2 million by 2026

Question 11

Biological & Psychological Underpinnings of BD:

Answer 11

High heritability, separate heritability of mania & depression, and genes for mania may involve reward pathways, i.e., dopamine function are all biological factors that lead or contribute to the onset of BD

Question 12

‘Resistance’ to Bipolar Disorder (Seal et al., 2008):

Answer 12

12 individuals aged 30+, most with a history of diagnosable hypomanic episodes, that never sought treatment, no history of clinical depression and no diagnosis of BD.
Key findings:=
High levels of functioning
Lower levels of catastrophizing about changes in internal states
Reported ‘awareness’ of behavior and social impact when feeling high

Question 13

NICE Guidelines for Bipolar Disorder (BD) Treatment in Primary Care

Answer 13

Review treatment and 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)

Question 14

NICE Guidelines for Bipolar Disorder (BD) Treatment in Secondary Care

Answer 14

Refer urgently if there is deterioration in depressive symptoms, signs of hypomania, or mania
Consider stopping antidepressant medication if mania or hypomania develops and offer an antipsychotic
Offer evidence-based psychological intervention

Question 15

Treatments for Bipolar Disorder (BD)

Answer 15

Medication: mood stabilisers (e.g., lithium), antidepressants, and antipsychotics
High relapse rates despite adequate medication (Solomon et al., 1995)
Psychological treatments: relapse prevention, psychoeducation, Family Focused Therapy, and Cognitive Behavioural Therapy

Question 16

Psychoeducation/Relapse Prevention

Answer 16

Provide information about bipolar disorder and how people with BD learn to cope better
Identify warning signs, also called ‘prodromes’ or ‘relapse signature’ – changes in thoughts, feelings, behaviours
Work collaboratively to identify effective coping strategies, e.g., relax, postpone behaviour, get feedback from family members

Question 17

Efficacy of Relapse Prevention Interventions

Answer 17

Perry et al., 1999: 7-12 sessions of individual relapse prevention vs. treatment as usual resulted in longer time to relapse with mania but no effects on time to relapse with depression
Colom et al., 2003: 21 sessions of group psychoeducation vs. treatment as usual resulted in reduced rates of relapse of mania and depression over 2 years

Question 18

Family Focused Therapy (FFT)

Answer 18

Work with families or groups of families
Provide psychoeducation to improve their understanding of bipolar disorder – non-blaming
Identify hostility, criticism, and overprotectiveness and help build up more collaborative, positive communication

Question 19

Efficacy of Family Focused Therapy

Answer 19

Miklowitz et al., 2003: 21 sessions of FFT psychoeducation and behavioural intervention vs. crisis management resulted in reduced relapse rates and mood symptoms over 2 years
Rea et al., 2003: compared FFT to psychoeducation and results documented FFT had lower rates of rehospitalisation

Question 20

Cognitive Behavioral Therapy (CBT) for Bipolar Disorder

Answer 20

CBT involves identifying negative automatic thoughts, challenging them, activity scheduling, developing coping strategies, and engaging in relapse prevention.
Lam et al., 2003, 2005 researched the efficacy of CBT with intervention of 20 sessions of individual CBT vs. treatment as usual. Results documented reduced symptoms of depression, longer time to relapse over 2 years, improved functioning.
STEP trial – Systematic Treatment Enhancement Programme (Milkowitz 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.

Question 21

Integrative Cognitive Model for Bipolar Disorder

Answer 21

A person flicks between periods of high and periods of low AS. Mood swings are a consequence of multiple, conflicted, extreme, personal appraisals of changes in internal state.
Leads to internal struggle trying to exert extreme control over internal states rather than active, successful ways of pursuing goals.
Hypomanic and Positive Predictions Inventory include beliefs about internal states within the model.
Key research on the model: Mansell et al. (2006), Mansell et al. (2011), Alatiq et al. (2011), Kelly et al. (2011).
Testing Conflicting Appraisals: Do conflicting appraisals of activated states discriminate bipolar disorder?

Question 22

TEAMS therapy for Bipolar Disorder

Answer 22

TEAMS therapy involves focusing on present problems, working through the principle of safety – engagement – experience – formulation – change, identifying core personal goals and values, exploring and monitoring internal states on a continuum, and identifying 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.
Goal identification, exploring internal states, plotting a continuum, pros and cons.

Question 23

Early Intervention Service for Bipolar Disorder

Answer 23

NICE guidelines (UK) recommend offering people with BD evidence-based psychological intervention(s). Cognitive Behaviour Therapy may be effective for people at-risk of BD.
Early intervention in psychosis services show health & economic benefits.
Youth service models propose to widen intake criteria to include BD & those at risk of developing BD. This could yield £29 million in savings in the UK.