Transcript Psychoeducation for Bipolar Disorders

‫به انم خدا‬
•sixth leading cause of disability worldwide
•burden of bipolar disorders on
functioning
persists far beyond acute episodes
•Relapse risk over a period of 5 years postrecovery of an
episode goes beyond 70 percent.
Psychological Approaches
 cognitive-behavioral therapy
 Interpersonal social rhythm therapy (IPSRT)
 Psychoeducation
Psychoeducation
 cures incomprehension, alleviates stigma, deals
effectively with guilt, and prevents learned
helplessness.
 Psychoeducation replaces guilt by responsibility,
helplessness by proactive care, and denial by
awareness.
What Is Psychoeducation?
 Training
 Psychoeducation is rather an information-based
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behavioral training aimed at adjusting lifestyle to cope
with bipolar disorder for improved outcome, including
enhancement of illness awareness
treatment adherence
early detection of relapse
avoidance of potentially harmful factors such as illegal
drugs and sleep deprivation.
main components Barcelona
Psychoeducation Program
 Illness Awareness
 Adherence Enhancement
 Substance Misuse Avoidance
 Early Warning Signs Detection
 Lifestyle Regularity (and Miscellanea)
Sessions of the Barcelona Psychoeducation
Program
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Introduction
What is bipolar illness?
Etiological and triggering factors
Symptoms (I): Mania and hypomania
Symptoms (II): Depression and mixed episodes
Course and outcome
Treatment (I): Mood stabilizers
Treatment (II): Antimanic agents
Treatment (III): Antidepressants
Serum levels: Lithium, carabamazepine, and valproate
Pregnancy and genetic counseling
Psychopharmacology versus alternative therapies
Risks associated with treatment withdrawal
Alcohol and street drugs: Risks in bipolar illness
Early detection of manic and hypomanic episodes
Early detection of depressive and mixed episodes
What to do when a new phase is detected
Regularity
Stress management techniques
Problem-solving techniques
Farewell
Illness Awareness
 helping to refocus the patient on the biological nature
of his or her condition and the need for
pharmacological treatment
 Patients generally learn quite quickly, though, to feel
comfortable within the medical model of the illness,
which may be much more helpful to deal with stigma
and guilt
What is bipolar disorder?
 concept of bipolar disorder
 dispel the numerous myths about it,
 stressing the biological nature of the disorder
 attempting to overcome its social stigma
Etiological and triggering factors
 explain the biological nature of the disorder
 “causal” concept of the disorder—underscored as
biological
 the “triggering” concept—which can be either
biological or environmental.
 Symptoms Mania and hypomania
 Symptoms Depression and mixed episodes
 Course and outcome :
focus on the chronic and recurring character of
bipolar disorder, further emphasizing the difference
between causal and triggering factors
Adherence Enhancement
 Almost a half of patients stop taking medication without
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indication from their psychiatrists, even during euthymia
The reasons for nonadherence are quite unspecific and
patient-dependent, although substance and personality
comorbidities play a major role.
Medication withdrawal is the most common cause of
relapse among bipolar patients. The risk of hospitalization
is four times higher among the patients who do not duly
comply with their maintenance treatment. Mortality,
especially by suicide, is also higher in nonadherent
patients.
Nonadherence is usually underestimated by clinicians.
Lack of adherence is often explained by irrational fears,
prejudice, and misinformation
 Poor adherence can be defined as the inability of the
patient to follow some or all of the instructions given
by his or her psychiatrist and psychologist, including
drug prescription and the facilitation of healthpromoting behaviors or habits
Substance Misuse Avoidance
 lifetime prevalence for co-occurring alcohol use
disorders reaching almost 60 percent of bipolar I
patients and a 38 percent lifetime prevalence of any
drug use disorder
 nearly half of bipolar II patients have a comorbid
substance use disorder.
 risk for a bipolar patient to suffer a substance-related
problem is sixfold higher than that of the general
population
 Substance use is associated with a poorer outcome:
Increased episodes of depression
increased adherence problems
delayed symptomatic recovery
 Alcohol may trigger depression, increase anxiety, worsen
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sleep, reduce impulse control, cause cognitive impairment,
increase aggressiveness, and the appearance of psychotic
symptoms and mania.
Marijuana may cause an amotivational syndrome
characterized by great apathy; it may also trigger
depression and mania, interfere with sleep, increase
anxiety, and psychotic symptoms.
Cocaine and hallucinogens all by themselves can trigger
any type of episode and also rapid cycling, anxiety,
aggressiveness, psychotic symptoms, poor sleep, and
cognitive impairment.
The danger of coffee is mainly its ability to alter sleep
structure and increase anxiety.
cigarette smoking,
five important points stop
smoking:
 is generally not a good idea to try to quit smoking during
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an episode.
The best time to quit smoking is during periods of longduration euthymia (6 months of euthymia or more).
Do not try to stop suddenly.
The use of substitutes is recommended (nicotine
chewing gum or patch) to avoid the withdrawal
syndrome, which may give rise to anxiety and irritability.
The use of anticraving drugs such as bupropion is
absolutely contraindicated in bipolar patients who are
not depressed, as they are antidepressants and might
eventually destabilize the disorder.
integrated group therapy
 IGT has shown its usefulness in decreasing the days of
substance use and other measures regarding the
severity of the substance disorder but not the outcome
of bipolar disorder.
Early Warning Signs Detection
 One useful comparison to help the patients
understand the need for early detection and treatment
of (hypo)mania is the avalanche
 Another key element of these sessions is the early
intervention plan
Warning Signs Detection
 three steps :
Step 1. Information: Frequent relapse signals
Step 2. Personalization
Step 3. Specialization
“Tips” against a Hypomanic Switch
 What to do if a hypomanic, mixed, or manic phase is suspected
Try to locate your psychiatrist or psychologist, even if by
telephone, so that he or she can evaluate the relapse or tell you it
is a nonpathological fluctuation.
 Increase the number of sleeping hours to a minimum of 10, even
if you need the sleeping drugs the psychiatrist prescribed for the
emergency plan. Often, sleeping long hours for 3 or 4 days will
be enough to stop the beginning of an episode, if done in time.
 Limit the number of activities and eliminate the ones that are
not absolutely essential. Normally the help of the support person
will be needed to decide which activities are not essential.
Remember that the only truly important thing is your health and
avoiding relapses; this outweighs any job or social commitment.
 Spend a maximum of 6 hours being active. The rest of the day
should be for resting or for relaxing, nonstimulating activities.
You should behave as if you had the flu: Lots of bed rest, a little
TV, few outings, and lots of tranquility
 Never try to overcome your hyperactivity and increased energy by
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trying to exhaust yourself, doing lots of physical exercise to get tired.
This is like trying to put out a fire with gasoline: The more activity you
do, the more stimulated you will be, and the worse the episode will get.
Physical exercise must be minimized.
Reduce stimuli: Avoid exposure to highly stimulating environments (a
discotheque, a demonstration, or a mall) and surround yourself with a
relaxing environment (quiet, little light, and few people).
Avoid stimulating beverages such as coffee, tea, cola drinks, and socalled energy drinks (containing taurine, ginseng, caffeine, or
derivatives of these substances). Also avoid multivitamins because they
sometimes contain some of these substances. Obviously, alcohol and
other drugs should be avoided.
Limit spending: Remove access to credit cards (your “lifeboat caregiver”
can hold onto them until the threatened episode disappears) and
postpone all purchases for at least 48 hours.
Never make important decisions if you suspect you are starting to
suffer symptoms of hypomania. Until the psychiatrist or psychologist
rules out the existence of an episode, you should postpone all decisionmaking.
Never give yourself permission to “go up a little more.” Remember that
the higher you go, the harder you fall.
“Tips” against a Depressive Switch
 What to do if a depressed phase is suspected
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Try to reach your psychiatrist by phone. When a depressive
phase starts or when you suspect this is happening, you should
not change psychiatrists, as the psychiatrist on duty may
overestimate your depressive symptoms without knowing that
you have bipolar disorder, and this may lead to overuse of
antidepressants.
You should never self-medicate for depressive symptoms. Carry
on taking the medication prescribed by the psychiatrist.
Sleep 8 hours at most, as sleeping longer can worsen the
depression. To limit sleeping time, it may be useful to schedule
activities for the morning.
Try to increase your activity level, even though this is just the
opposite of what you want to do. Do not leave out any of your
daily activities.
It is very important to do some physical exercise; if you cannot go
to the gym or go swimming, try to walk half an hour every day.
 Do not make important decisions—these should be made only when
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you are fully lucid. They should not be influenced by the pessimism
and despair characteristic of depressive states. If you make decisions at
the beginning of a depression, then the decision is probably being
made by the depression, not by you.
Do not consume alcohol, marijuana, or cocaine to try to cheer yourself
up or be more active: These substances will leave you even more
depressed after a few hours. If you do not have anxiety problems, you
can drink a couple of cups of coffee for stimulation.
Try to put notions of inferiority and pessimism in perspective: They are
just the result of biochemical changes in the brain. If you talk about
them to a “lifeboat caregiver,” he or she will probably tell you that you
are blowing up the importance of these notions.
Try to keep to a regular schedule; many depressed people feel better in
the afternoon, so they go to bed later and later, and end up with
upside-down sleeping hours. It is best to go on living during the day
and sleeping at night.
Move up your visit to the psychologist; he or she will give you advice on
how to deal with this initial relapse. If you have suicidal ideas,
immediately let your therapist know about them: Remember they are
always a symptom.
A valid warning sign must:
 Be behavioral
 Be regular for all episodes
 Be regular for all episodes
 Be easily identifiable
 Be subtle
 Be operative
 Not lead to arguments
 Escalate to the symptom
Lifestyle Regularity :
 Sleeping habits/circadian rhythm
general advice in psychoeducation is to sleep between
7 and 9 hours, avoid daytime sleep, and use sleep both
as an indicator of relapse and as a helper to deal with
oncoming episodes
Lifestyle Regularity
 Physical exercise
doing physical exercise is highly recommended for bipolar
patients, not only to improve general health but also to
improve mood
Physical exercise should not be done 3 to 4 hours before
going to bed, as its stimulant properties may worsen the
quality of sleep.
 Physical exercise should be stopped if a manic, hypomanic, or
mixed relapse is suspected. Similarly, it should be increased if
a depressive relapse is suspected.
 Physical exercise often implies some risk of dehydratation.
This should be kept in mind especially with those patients on
lithium, due to intoxication risk
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