Transcript Social and Familial Factors in the Course of Biplar Disorder: Basic

Social and Familial Factors
in the Course of Bipolar
Disorder: Basic Processes
and Relevant Interventions
By David Miklowitz & Sheri Johnson
Presented by Liz Lusk
Bipolar Disorder 101
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What is a Major Depressive Episode?
Must have 5 or more of the following symptoms during same
2-week period (depressed mood or loss of interest of
pleasure are necessary)
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Depressed mood most of the day, nearly every day
Diminished interest or pleasure in almost all activities
Weight gain / weight loss, increase or decrease in appetite
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness or excessive guilt
Inability to think or concentrate
Recurrent thoughts of death
Bipolar Disorder 101
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What is a Manic Episode?
Distinct period of abnormally and persistently elevated,
expansive, or irritable mood lasting at least 1 week (or any
duration if hospitalization is necessary)
Must have 3 or more of the following symptoms (4 if the
mood is only irritable)
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Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas / racing thoughts
Distractibility
Increase in goal-directed activity
Excessive involvement in pleasurable activities that are high risk
Bipolar Disorder 101
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What is a Mixed Episode?
Criteria are met both for a Manic Episode and for a Major
Depressive Episode (except for duration) nearly every day
during at least a 1 week period
What are the two major differences between a Manic and
Hypomanic Episode?
Time frame: distinct period of persistently elevated,
expansive, or irritable mood, lasting throughout at least 4
days
Severity: Episode is not severe enough to cause marked
impairment in social or occupational functioning
Bipolar Disorder 101
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What is the difference between Bipolar Disorder
I and Bipolar Disorder II?
Bipolar I: characterized by the occurrence of
one or more Manic Episodes or Mixed
Episodes. Often individuals have also had one
or more Major Depressive Episodes (but not
necessary for diagnosis)
Bipolar II: characterized by the occurrence of
one or more Major Depressive Episode
accompanied by at least one Hypomanic
Episode (never a manic or mixed episode)
Bipolar Disorder (BD)
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Affects about 2-4 % of the U.S. population (Merikangas et al., 2007)
National Comorbidity Survey Replication found that Bipolar I and II
affect 2.6 %, with 82.9% of those being categorized as serious in
severity (17.1% moderate and 0 mild)
Course can be looked at from a developmental psychopathology
perspective with episodes resulting from a complex interaction
between genes, neurobiology, stress and psychological
vulnerabilities at different points in development.
http://www.webmd.com/bipolar-disorder/bipolar-tv/default.htm
Miklowitz and Johnson review the evidence for the role of social
variables, live events, family discord and psychological variables in
the course of BD, then briefly reviews effective interventions
Personality and Temperament
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BD patients often diagnosed also with personality disorders,
with Cluster B personality disorders being most common
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When examining BD individuals in remission, found a co-diagnosis in
28.8% of participants (George, Miklowitz, Richards, Simoneau & Taylor,
2003)
In 100 BD participants, found that 30% met criteria for a cluster B
personality disorder (Garno, Goldberg, Ramirez and Ritzler, 2005)
Individuals with BD report higher global positive affect in their
everyday lives regardless of how it is was measured
Undergrads at risk for hypomania endorsed high levels of
dispositional pride and joy, but do not tend to show elevations
of more prosocial positive emotions (love and compassion)
Personality and Temperament
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Neuroticism has received much research attention
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Lahey reported in his article “Public Health Significance of Neuroticism”
that out of all the Axis I disorders, the effect size was largest between
neuroticism and mood disorders
Two cross-sectional studies found neuroticism to be related to the
severity of depressive symptoms in those with BD or with
undiagnosed symptoms
Relatively higher rates of depressive symptoms seen in bipolar II
than in bipolar I disorder so you may expect elevated neuroticism or
other negative affectivity in BPD II
BD II described themselves as more labile in mood, sensitive, and
brooding than those with BD I. They also endorsed being highly
energetic and assertive.
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Suggests that interepisode temperamental variables can be informative
during periods of recovery in distinguishing between different forms of
mood disorders
Personality and Temperament
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Among those with BD who have a comorbid personality
disorder, the course of the mood disorder is worse
Research has also focused on predicting future manic
episodes versus depressive symptoms from personality
profiles
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Trait positive affectivity has been found to predict a more severe
course of mania over a 6 month period among people already
hospitalized for BD (baseline levels of positive affectivity may be
important as a predictor of the course of manic symptoms)
Assessing temperamental and personality variables could help
clinicians distinguish between BD I, II and MDD, especially in
those in remission, and identify those at risk for depression and
at greater risk for severe mania
Context is important
Life Events
Focus on 3 types of events related to BD: negative life events,
social-rhythm disrupting and goal attainment
Negative life events
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2 out or 3 cross-sectional studies found that negative life events were
more common in the months before a bipolar depressive episode than
during control intervals
Severe independent negative events associated with increase in risk of
relapse as well as increase in time until recovery
Negative life events also associated with recurrence of depressive
symptoms in college students at risk for BD who had negative cognitive
styles (mediation / moderation?)
Chronic interpersonal stress in adolescents (family and romantic
relationships) experienced more sustained depressive symptoms over
time
Overall do not see same effect of negative life events on mania
Life Events
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Live events that Disrupt Social Rhythms
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Evidence suggests that BD is related to poor
regulation of sleep and circadian rhythms
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Sleep disruption can trigger manic symptoms (more than 10% of
patients with bipolar depression develop hypomanic or manic
symptoms after induced sleep deprivation)
Biological circadian rhythms and schedule disrupting life events
Life Events
Goal-Attainment Life Events
Growing body of research on sensitivity to cues of
reward – stemming from observations that mania may
be tied to brain regions involved in regulating
responses to reward cues
Elevated activity in the basal ganglia and ventral
tegmental area (regions involved in reward sensitivity)
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Basal ganglia activity particularly elevated during periods of
mania
Reward pathways may be overly sensitive in BD
Which came first the chicken or the egg?
Dopamanergic pathways trigger positive affect. When the
system is activated you get increased effort, energy, focus on
goal pursuit…sound familiar?
Reward sensitivity also predicts increases in manic symptoms
Impairment in Family Relationships
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Low social support predicts higher levels of depression over
time among those with BD
Expressed Emotion (EE) – is an index of the degree to which
caregiving relatives express critical, hostile, or emotionally
overinvolved or overprotextive attitudes toward the patient
when interviewed during or shortly after an acute episode
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Several longitudinal studies show high EE in family is
associated with higher rates of relapse
The EE/outcome relationship appears to be stronger for
depressive than manic relapses in Bipolar I
Family impairment and poor family problem solving also related
to depressive symptoms…why?
Family support can be a protective factor
http://www.youtube.com/watch?v=WCsUJ380ww8
Impairment in Family Relationships
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Expressed Emotion (EE) continued…
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During period of stabilization, high EE family members of bipolar
I individuals are more likely to attribute negative events to
personal and controllable factors than low-EE families (same
seen in families of those with MDD and Schizophrenia)
High EE couples/families - characterized by high conflict that is
bidirectional and negative interactions that escalate and become
personal
Low EE – able to interrupt escalations
Negativity also associated with relapse
Family Factors in Childhood-Onset
Bipolar Disorder
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Family can be a risk factor or protective factor
depending on when BD is diagnosed, if parents have
mood disorders, conflict resolution style and whether the
family is intact
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Sometimes family impairment is more of a function of the
parent’s diagnoses than the parent’s reactions to their children’s
BD
When child had BD, the association between
parental and child diagnoses was mediated
by whether parents reported
high levels of family conflict.
Facial Emotion Processing
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The accurate perception of facial emotions is believed to be
key to social competence and conflict resolution since one
must code subtle changes in another’s emotion in order to
respond effectively
Studies show that bipolar adults show impairments in
processing facial emotion
Bipolar youth make facial emotion recognition errors as well
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BD children are likely to misclassify neutral facial expressions
as hostile and threatening, even though they don’t rate
angry faces as more angry than healthy controls
BD youth, regardless of emotion, require more intense facial
expressions before accurate identification of emotion
No study to date has demonstrated that emotion labeling deficits
predict the onset of BD in genetically at risk youth
Interventions
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Need combination of medication and psychosocial
interventions
Family, group, interpersonal and cognitive-behavioral
approaches to relapse prevention and episode stabilization
found to be effective
Common element: psychoeducation
Comparative effects of different forms of psychotherapy were
examined in a large-scale randomized trial conducted across
15 sites, known as the Systematic Treatment Enhancement
Program for Bipolar Disorder (STEP-BD)
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http://www.stepbd.org/
Miklowitz & Johnson Summary
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Review of research illustrates that personality, temperament,
life stress and family discord are important influences on the
course of BD
How do you see these variables interacting with each other to
influence the course of BD?
Future research to focus on replication, looking at the
interactions of risk and protective factors at different phases
of the life cycle, cost effective methods for training clinicians
and the identification of subgroups of
patients who respond best to each form
of treatment.