Week 9 Lecture 9 - bipolar disorder

Question 1

What is the Mood Disorder Questionnaire?

Answer 1

a self-report inventory that screens for
a lifetime history of (hypo)manic experiences

Question 2

What did a study by Udachina, A., & Mansell, W. (2007) investigating Self-reported History of Hypomanic Symptoms
in a Student Population find?

Answer 2

most students had experienced at least 1 symptom of hypomania

Question 3

What are the characterisations of mood episodes in bipolar disorder?

Answer 3

• 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

Question 4

What are the symptoms of major depression?

Answer 4

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

Question 5

What are the symptoms of mania and hypomania?

Answer 5

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

Question 6

What are some predictors of relapse in mood disorders?

Answer 6

• 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

Question 7

What is 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

What are the different types of other specified bipolar disorder?

Answer 8

• 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

Question 9

What is the Bipolar at Risk (BAR) criteria?

Answer 9

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

Question 10

What did early detection of BD focus on?

Answer 10

familial risk and identification of state-trait factors

Question 11

Does BAR criteria have predictive validity?

Answer 11

yes

Question 12

Can BAR criteria be used to reliably assess someone in an NHS context?

Answer 12

yes

Question 13

Does BAR criteria hold clinical utility?

Answer 13

yes

Question 14

What is the importance of early identification in BD?

Answer 14

• 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

Question 15

What are some biological factors of mood disorders that should be taken into account?

Answer 15

• high heritability
• separate heritability of mania and depression
• genes for mania may involve reward pathways i.e., dopamine function

Question 16

Seal et al. (2008) investigated “resistance” to BD.

Who were the ppts?

Answer 16

• 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

Question 17

Seal et al. (2008) investigated “resistance” to BD.

What were the key findings?

Answer 17

• High levels of functioning
• Lower levels of catastrophising about
  changes in internal states
• Reported ‘awareness’ of behaviour and
  social impact when feeling high

Question 18

what are the NICE guidelines for treating BD?

Answer 18

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

Question 19

What are the treatments for BD?

Answer 19

• medication
• psychological treatments

Question 20

What are the medications for BD?

Answer 20

• mood stabilisers (e.g. lithium) but also anti-depressants, and ant-psychotics
• However high relapse rates despite adequate medication

Question 21

What are the psychological treatments for BD?

Answer 21

• relapse prevention or psychoeducation
• family focused therapy
• CBT

Question 22

What does psychoeducation/ relapse prevention provide?

Answer 22

Provide information about bipolar disorder and how people with bipolar disorder learn to cope better

Question 23

What does psychoeducation/ relapse prevention identify?

Answer 23

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

Question 24

Who does psychoeducation/ relapse prevention work with?

Answer 24

Work collaboratively to identify effective
coping strategies, e.g. relax, postpone
behaviour, get feedback from family members

Question 25

Give 2 examples of studies on the efficacy of relapse prevention

Answer 25

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

Question 26

Who does Family Focused Therapy work with?

Answer 26

Work with families or groups of families

Question 27

What does Family Focused Therapy provide?

Answer 27

Provide psychoeducation to improve their understanding of bipolar – non-blaming

Question 28

What does Family Focused Therapy identify?

Answer 28

Identify hostility, criticism and overprotectiveness & help build up more collaborative, positive communication

Question 29

Give 2 examples of studies on the efficacy of FFT

Answer 29

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

Question 30

What is CBT for BD?

Answer 30

- 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

Question 31

Give 2 examples of studies on the efficacy of CBT

Answer 31

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

Question 32

What is an integrative Cognitive Model (BD)

Answer 32

- 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

Question 33

What are the subscales of the Hypomanic and Positive Predictions Inventory (HAPPI)(Mansell et al. 2006)?

Answer 33

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

Question 34

What does TEAMS therapy involve?

Answer 34

- 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

Question 35

Give a brief summary of what TEAMS therapy involves

Answer 35

- 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

Question 36

From bottom to top, what is the pyramid of therapy principles that is followed in the TEAMS therapy?

Answer 36

- safety - engagement - experiential processing - awareness of formulation - change and recovery

Question 37

What is the next research priority for BD?

Answer 37

- 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