Week 9 Lecture 9 - bipolar disorder Flashcards
What is the Mood Disorder Questionnaire?
a self-report inventory that screens for
a lifetime history of (hypo)manic experiences
What did a study by Udachina, A., & Mansell, W. (2007) investigating Self-reported History of Hypomanic Symptoms
in a Student Population find?
most students had experienced at least 1 symptom of hypomania
What are the 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
What are the symptoms of major depression?
At least 2 weeks of:
-Depressed mood
and / or
-Markedly diminished interest or pleasure in activities
Plus at least three symptoms:
-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
What are the symptoms of mania and hypomania?
Mania (at least 1 week )
Hypomania (at least 4 days) of:
- abnormally + persistently elevated, expansive or irritable mood
and
- abnormally & persistently increased activity or energy
Plus 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 in goal-directed activity
- Excessive involvement in pleasurable activities - may have high potential for painful consequences
Mania must lead to marked impairment in social or occupational functioning, hospitalisation, or psychosis
What are some predictors of relapse in mood disorders?
- Stressful interpersonal life events
-High ‘Expressed Emotion’ (hostility, overprotectiveness, criticism) in family members
-Disrupted social rhythm events including
sleep changes
*Goal-attainment Events *manic symptoms and not depression
What is 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
- Or other important areas of functioning
What are the different types of 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 - Other (describe)
- Unspecified
What is the Bipolar at Risk (BAR) criteria?
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
What did early detection of BD focus on?
familial risk and identification of state-trait factors
Does BAR criteria have predictive validity?
yes
Can BAR criteria be used to reliably assess someone in an NHS context?
yes
Does BAR criteria hold clinical utility?
yes
What is the importance of early identification in BD?
- 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
What are some biological factors of mood disorders that should be taken into account?
- high heritability
- separate heritability of mania and depression
- genes for mania may involve reward pathways i.e., dopamine function
Seal et al. (2008) investigated “resistance” to BD.
Who were the ppts?
- 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
Seal et al. (2008) investigated “resistance” to BD.
What were the 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
what are the NICE guidelines for treating BD?
Primary Care:
- Review treatment & care, inc medication
- Offer choice of an evidence-based psychological intervention
developed for BD
Secondary Care (for deterioration in depressive symptoms, signs of hypomania, or mania (refer urgently)):
- Pharmacological interventions:
* If mania/hypomania develops & person is taking antidepressant, consider
stopping the antidepressant and offer an antipsychotic
- Offer evidence-based psychological intervention
What are the treatments for BD?
- medication
- psychological treatments
What are the medications for BD?
- mood stabilisers (e.g. lithium) but also anti-depressants, and ant-psychotics
- However high relapse rates despite adequate medication
What are the psychological treatments for BD?
- relapse prevention or psychoeducation
- family focused therapy
- CBT
What does psychoeducation/ relapse prevention provide?
Provide information about bipolar disorder and how people with bipolar disorder learn to cope better
What does psychoeducation/ relapse prevention identify?
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
Who does psychoeducation/ relapse prevention work with?
Work collaboratively to identify effective
coping strategies, e.g. relax, postpone
behaviour, get feedback from family members
Give 2 examples of studies on the 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
Who does Family Focused Therapy work with?
Work with families or groups of families
What does Family Focused Therapy provide?
Provide psychoeducation to improve their
understanding of bipolar – non-blaming
What does Family Focused Therapy identify?
Identify hostility, criticism and
overprotectiveness & help build up more
collaborative, positive communication
Give 2 examples of studies on the efficacy of 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
What is CBT for BD?
- 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
Give 2 examples of studies on the efficacy of CBT
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
- But effect sizes are modest, and focus is on prevention of relapse rather than current symptoms and recovery
What is an integrative Cognitive Model (BD)
- 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
e.g.,
feelings of high energy = imminent success
vs. feelings of high energy = mental breakdown
What are the subscales of the Hypomanic and Positive Predictions Inventory (HAPPI)(Mansell et al. 2006)?
rate how much you believe statements on a scale of 1-100
- Social Self Criticism –> reflecting self-critical beliefs and beliefs that others were critical, particularly in a social context
- Increasing Activation To Avoid Failure –> beliefs about needing to remain ‘on the go’ and active in order to avert failure provide another predisposing factor for striving to experience highly activated states
- Success Activation & Triumph Over Fear –> beliefs about extreme optimism and self-confidence, invincibility and desirability
- Loss of Control –> includes items pertaining to losing control of moods and thoughts
- Grandiose Appraisals of Ideation –>extreme social aspirations and positive appraisals of idea generation reflected a cognitive style consistent with an ‘achievement striving’ personality
- Regaining Autonomy –> includes beliefs about ignoring advice from others and striving for autonomy
What does TEAMS therapy involve?
- Focused on present problems, e.g. depression, anxiety
- 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
Give a brief summary of what TEAMS therapy involves
- goal identification –> Expressing needs is a major factor in recovery
- exploring internal states –> Feelings are a normal and important part of life
- plotting a continuum –> thinking in “shades of grey” is more effective than black and white
- pros and cons –> all moods have both advantages and drawbacks
From bottom to top, what is the pyramid of therapy principles that is followed in the TEAMS therapy?
- safety
- engagement
- experiential processing
- awareness of formulation
- change and recovery
What is the next research priority for BD?
- treatments for Bipolar at risk
- CBT may be effective for people at-risk of BD
- early intervention in psychosis showed health and economic benefits
- if applied to BD and those at risk of BD, this could yield £29 million in savings in the UK
