Transcript Psychotherapy For Bipolar Disorder

Psychotherapy For
Bipolar Disorder
Brooke Tompkins
Overview
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Bipolar Diagnoses
History and Facts
Etiology
Cognitive-Behavior Therapy
Interpersonal and Social Rhythm Therapy
Empirical Support
DSM-IV Diagnoses
DSM-IV Manic Episode
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Abnormally and persistently elevated, expansive, or
irritable mood, lasting at least 1 week (or any duration if
hospitalization is necessary).
Three (or more) of the following symptoms have
persisted (four if the mood is only irritable):
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2.
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inflated self-esteem
decreased need for sleep
pressured speech
flight of ideas or racing thoughts
distractibility
increase in goal-directed activity
increased involvement in pleasurable activities with a high
potential for negative consequences
DSM-IV Major Depressive Episode
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Five (or more) of the following symptoms have been
present during the same 2-week period; at least one of
the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
1.
2.
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9.
depressed mood most of the day, nearly every day. Note: In
children and adolescents, can be irritable mood.
lost of interest or pleasure in activities
significant weight loss or weight gain
insomnia or hypersomnia
psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness
diminished ability to think or concentrate
suicidal ideation
DSM-IV Mixed Episode
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Symptoms of a Manic Episode and a Major Depressive
Episode nearly every day during at least a 1-week period.
cause marked impairment
DSM-IV Hypomanic Episode
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Elevated, expansive, or irritable mood, lasting at least 4
days, that is clearly different from the usual nondepressed mood.
Three (or more) of the symptoms of a manic episode
have persisted (four if the mood is only irritable).
The episode is uncharacteristic of the person when not
symptomatic.
Observable by others.
Does not cause marked impairment in social or
occupational functioning, and does not necessitate
hospitalization.
DSM-IV Bipolar Disorder
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Bipolar Disorder I
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Bipolar Disorder II
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At least one manic or mixed episode (lasting for at least a week)
within his or her lifetime.
A depressive episode is not a diagnostic criteria
At least one episode of hypomania
at least one episode of depression
Rapid Cycling – 4 or more episodes in a year
Bipolar NOS
DSM-IV Cyclothymic Disorder
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For at least 2 years
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hypomanic symptoms
depressive symptoms
Not without symptoms for more than 2 months at a
time.
Prevalence and Comorbidity
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Lifetime prevalence:
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Current point prevalence 18+ (NIMH) = 2.6%
Median age of onset:
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0.8-1.6%
Late adolescence, early 20s
Rate among adolescents is increasing (estimate of 1%)
Comorbidities
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50% with alcohol or substance abuse disorders
60% with anxiety disorders (Panic Disorder & Social Phobia)
33-50% with personality disorders
Comorbidity is the rule rather than the exception
Associated with poorer course over time
Diagnostic Issues
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One-third to one-half of bipolar I disorder patients
experience psychotic symptoms (usually brief - less than
2 weeks)
~ 40% of those with bipolar disorder are first diagnosed
with unipolar depression (2004)
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Treated with antidepressants – leads to about 25% of these
individuals experiencing iatrogenic manic symptoms
Up to 75% do not adhere to medication regimens
Etiology - Biological Basis
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Heritability as high as 80%
First-degree relatives
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Polygenic
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Involves a combination of several genes
New research - genetic vulnerability traits
How?
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10% chance of bipolar disorder and unipolar depression
Dysregulation of neurotransmitters
Difficulties in maintaining homeostasis
Symptoms likely under neurobiological stressors (i.e., sleep
deprivation)
Different brain activity
Etiology – “Diathesis-Stress”
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Biological predisposition + stressful events + subjective
perception (“cognitive triad”)
Negative life events predict bipolar depression
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But…combined with a high behavioral activation system triggers mania
Excessive focus on goal attainment stimulates manic episode
Etiology - Circadian Dysregulation
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Biological Rhythms
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Seasonal peaks
Suicide
Sleep patterns
Social Rhythm Stability Hypothesis (Frank et al.)
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Changes in routine (sleep cycles, appetite, energy, work, etc.) can
cause great stress on the body, especially in more vulnerable
individuals
Then and Now
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Most “biological” of severe psychiatric disorders
Previously thought amenable only to
pharmacotherapy
Psychoanalysis – not effective
1980s
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Improving pharmacological treatments
Important challenge – treating chronic subacute depressive
symptoms
Beginning of research on psychotherapy
Pharmacotherapy
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First line of treatment
Strongest support:
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Lithium (1949)– recommended by APA Practice Guidelines
¾ report side effects, leads to discontinuation and
hospitalization
Mood stabilizers are less effective in reducing
depressive symptoms
Mood stabilizers + antidepressants + antipsychotics
Psychotherapy as adjunct to pharmacotherapy
Know about medications!
Why Psychotherapy?
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Provide psychoeducation regarding symptoms
Promote adherence with medication regimens
Address comorbid conditions
Ameliorate stigma and self-esteem consequences
Enhance social and occupational functioning and
adjustment
Reduce risk of suicide
Identify psychosocial triggers that increase the risk for
relapse
Evidence suggests that psychosocial treatments both
reduce and prevent symptoms
Current Treatment Guidelines
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American Psychiatric Association, 2002
Initiating mood stabilizing treatment
Add one or more of the following:
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Specific psychotherapy
Antidepressant medication
APA Practice Guidelines
Supported Types of Psychotherapy
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Interpersonal and Social Rhythm Therapy (IPSRT)
Cognitive-Behavior Therapy (CBT)
Group or Individual Psychoeducation
Family Therapy
All trials of psychotherapy as complementary to
pharmacotherapy (Swartz, Frank, & Kupfer, 2006)
Possible phase-specific treatments
Differential effects of psychotherapies
Effect on recurrence
or relapse?
Effect on symptoms?
Experienced
Therapists?
Mania
Depression
Mania
Depression
Individual
Psychoeducation
No
Yes
No
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Group
Psychoeducation
Yes
No
Yes
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Typical Care
Management
No
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Yes
No
Cognitive
Therapy
Yes
Yes
Yes
No
Yes
IPSRT
Yes
Yes
Yes
Yes
Yes
Therapy Type
Swartz, Frank, & Kupfer, 2006
Assessment of Symptoms
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Self-Report
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Clinical Evaluation
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Mood Disorders Questionnaire (Hirschfield, 2002)
SCID-IV
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.61-.64 reliability
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.76-.78 reliability when used with medical records
Assessment of Symptom Severity
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Inventory for Depressive Symptomatology (IDS-C; Rush et al., 1986)
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Bech-Rafaelsen Mania Scale (Bech et al., 1979)
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Young Mania Rating Scale (YMRS; Young et al. 1978)
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Manic State Rating Scale (Beigel, Murphy, & Bunney, 1971)
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Assess medication compliance
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Assess for suicide!
Cognitive –Behavior Therapy
Focuses on the cycle of reactions to
symptoms that impair functioning, cause
psychosocial problems, and increase stress
Cognitive-Behavioral Process
6.
Psychoeducation
Reactive Symptom Management
Symptom Monitoring/Develop Early Warning
System
Adherence to Treatments
Symptom Control (CBT and cognitive strategies)
Reducing Stress
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Generally around 12-20 sessions
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Every Session
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Collaborative agenda setting
Mood and medication assessment
Review homework
Setting goals and priorities for session
Assigning new homework
Final summary and feedback
Psychoeducation
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Explain disorder and role of cognition
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BD runs in families
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“Diathesis-stress” disorder - biological problem interacts with
stress
Can be dangerous to health, relationships, occupational success,
etc.
Much due to “cognitive triad”
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Involves biochemical problems that can cause symptoms such as
anger, impulsivity, depression, suicidality, exuberance,
hypersexuality, and a false sense of invinciblity
Explain negative explanatory style
Can be treated with both medication and psychotherapy
Psychoeducation
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Explain purpose of CBT treatments
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Learn to adopt constructive outlook on life
Problem-solving
Improve quality of life
Ease of medication adherence
Less likelihood of relapse
Introduce importance of homework
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Can assign reading materials for homework
Finding Peace of Mind: Treatment Strategies for Depression and
Bipolar Disorder
Bipolar Disorder
Psychoeducation
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Knowledge of medication and adherence
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Why medication is used
Side effects
Mood stabilizing vs. antidepressant
Expected outcome
Long-term issues with management
Why psychotherapy is needed in addition
Identify issues to discuss with physicians
Provide readings
Managing Hypomanic/Manic Symptoms
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Recognize warning signs
Interventions and Rules:
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Medical solutions first
Two-person feedback rule for “great ideas”
Limit cash payments
To counteract impulsivity:
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Give car keys or credit cards to someone to keep
Rules about staying out late or giving out phone #
Avoid alcohol and substance use
minimize stimulation
48-hours before acting rule
* Treatment Contract
Managing Hypomanic/Manic Symptoms
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Interventions (cont’d)
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Imagery about worst-case scenarios
Relaxation techniques
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Diaphragmatic breathing
PMR
Address wish to stay manic:
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They will feel more creative, productive, attractive, etc.
Remind them that some of the worst events in their life have
happened during manic episode
Ultimately, decisions will lead to more disruption
Symptom Monitoring
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Identify how day-to-day experiences are related to symptoms of
bipolar disorder
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Ask how illness has affected their lives and home environment
Complete Symptom Summary Worksheet
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List of symptoms
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Homework: Provide copies for patient to add symptoms throughout the
week
Teach patient to monitor key symptoms, such as changes in mood
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Circle what they experience in episode
Circle what they experience when normal
Review Mood Graph in session, complete for yesterday and today
Homework: Keep mood graphs.
Remember to always address homework at beginning of the next
session
Development of Early Warning System
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Complete Life Chart
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Reference line that represents a normal/euthymic state
Draw episodes of mania, depression, and mixed states on
timeline
Draw first episode together, they complete the rest
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Can consult with family members, medical records, etc.
Include types and dates of received treatment
Development of Early Warning System
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Develop early warning system
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Distinguish between “normal” and “abnormal” mood shifts
Using Symptom Summary Worksheet and Life Chart
Make detailed descriptions of patient in normal and episodic
states
Descriptions used by patient, family members, can call therapist
and review
*use mood graphs
Treatment Adherence
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Introduce CBT model of adherence
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Noncompliance is the norm, not the exception
Illness interferes with adherence
New conceptualization of adherence:
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Waxes and wanes over time
Difficulties from family, differing opinions, anger at some
medications not working, etc.
Strategies to reform opinion on illness, medications, and
necessity of treatment
Compliance Contracts
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Assessment and Goals
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Identify Obstacles
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Review dosing schedules
Review appointment plans
Goals for homework assignments
Intrapersonal
Treatment
Social system
Interpersonal
Cognitive
Make plan for overcoming obstacles
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Ask about past successful strategies
Make a plan
Periodically review and modify if necessary
Example Compliance Contract
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Step 1: Treatment Plan
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I, [patient name], plan to follow the treatment plans listed
below:
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Take 900 mg of lithium at bedtime.
Take 4 mg of Ambien to help me sleep.
See the doctor every month and call if I think the regimen needs to
be changed.
Step 2: Compliance Obstacles
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I anticipate these problems in following my treatment plan:
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If I continue to gain weight with lithium I may want to stop taking it.
The Ambien might stop working and I’ll need something stronger.
When I get home late I’m too tired to go to the kitchen to take my
pills.
Example Compliance Contract
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Step 3: Plan for reducing obstacles
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To overcome these obstacles, I plan to do the following:
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Join Weight Watchers. Start walking in my neighborhood.
Improve sleep by not drinking coffee or other caffeinated beverages
after 4 pm.
Keep the evening dose at the bedside with a bottle of water.
CBT Strategies for Symptom Control - Manic
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Goal: Testing Reality of Thoughts and Beliefs
Discuss typical hypomanic cognitive errors
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overreliance on luck
underestimating risk of danger
overestimating capabilities
disqualifying negative, minimization of life’s problems
overvaluing immediate gratification
misinterpreting intentions of others
Discuss automatic thoughts and distorted cognitions
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If difficult to identify, describe general impressions and images
until they can identify beliefs, themes, concerns
Use Automatic Thought Records
CBT Strategies for Symptom Control - Manic
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Alert them to the impact the thought has on their mood
state
Use behavioral experiments to test thought
Consult with trusted others
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Examine evidence
List evidence for/against
Alternative explanations
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Cognitive restructuring to evaluate thoughts
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Homework: Keeping Automatic Thought Records.
CBT Strategies for Symptom Control - Manic
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Goal: Modifying Behavioral Symptoms
Negative Imagery
Activity Scheduling
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“A” and “B” lists
Plan activities ahead of time
Can make a Daily Activity Schedule
Increasing sitting and listening
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Sit when they notice they are speaking or moving rapidly in
social situations – interrupts acceleration of motor activity
Focus on listening to others – use self-statement prompts if
needed
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“Pay attention. Listen to [name of person].”
Advantages/disadvantages technique
Advantages/Disadvantages Technique
Stay at Current Job
Advantages
It’s close to home
***Can make more money
*Good secretary
Larger office
*I know everybody
**More independence
Get away from boss
Business has been poor
Disadvantages
Change Jobs
***Stuck with current boss
The work schedule may
require weekend work
***No raise this year
***May have to move family
Bad neighborhood
New boss could be a jerk
No room for creativity
CBT Strategies for Symptom Control - Manic
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Stimulus Control
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Knowing what activities to avoid
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Alcohol or other substances
Unsupervised spending of large amounts of money
Daredevil hobbies
Exaggerated generosity or friendliness with strangers
Activities using a lethal weapon
Consulting with others
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Feedback
CBT for Symptom Control – Manic & Depressive
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Sleep Enhancement
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Be consistent
It’s a nighttime thing
Keep your bed a place for sleep
Get comfortable
Gear down for the night
Avoid stimulants that might keep you awake
Don’t do:
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Caffeine
Internet
TV and books
Chores
Exercise
CBT Strategies for Symptom Control - Depression
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Goal: Testing reality of negative thoughts
Identification of Negative Automatic Thoughts
Automatic Thought Record
“Evidence for/evidence against” technique
Alternative Explanations
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Reframe thoughts of suicide
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Patient chooses explanation that seems most likely
Have them write down reasons to live
Homework: Keep Automatic Thought Records.
CBT Strategies for Symptom Control - Depression
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Goal: Increase behavior
Discuss behavioral aspects of depression
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Normalize feeling overwhelmed and overloaded
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Graded Task Assignment
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How have they coped with it in the past?
List all tasks that require attention
Divide tasks into smaller steps
Devise plan to guide patient from one step to the next
“A” and “B” lists to help choose important tasks
CBT Strategies for Symptom Control - Depression
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Goal: Increase behavior (cont’d)
Increasing Mastery and Pleasure
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Discuss rationale for activity scheduling:
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breaks cycle of hopelessness
natural antidepressant effects
in contact with others
increase self-efficacy
positive outcomes
CBT Strategies for Symptom Control - Depression
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Adding Positives
1.
Select a healthy habit to improve
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Start one new behavior that gets them closer to goal
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3.
Ex: healthy eating
Ex: eat breakfast in morning
Select one problematic behavior to stop
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Ex: Stop eating late at night
Decision-Making
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Decision Making and Thought Processes
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Schedule time at end of day to review the day
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Review the day and take notes on events that were troublesome
or require more thought
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At least 1 hour before bedtime
Not in bed
Things to do the next day
Conversations
Disappointments, worries
For each item, note what needs to be done to rectify issue
At bedtime, instead of ruminating, remind self that day has
already been reviewed
Decision-Making
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Decision Making using Advantages/Disadvantages
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Provides structure
Can compare choices relative to one another
Consider maximizing advantages of each choice while
minimizing disadvantages
Problem-Solving
1.
Problem identification and definition
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State problem as clearly as possible
Generation of potential solutions
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List all possible solutions regardless of feasibility
Eliminate less desirable or unreasonable choices
Order in terms of preference
Pros and cons
Specify how and when solution is implemented
Problem-Solving
3.
Implement Solution
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Implement as planned
Evaluate effectiveness
Decide whether a revision is needed or a new plan to address
problem better
Or return to step #2 and select new solution
Ask questions to facilitate problem definition
Reducing Stress
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Acute Stress Management
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Inquire about past coping methods
YOU have faith in their ability to cope
Relaxation training
Stress Control and Problem Solving
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Cues to stress
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Internal and external
Physical
Emotional shifts
Input from others
Reducing Stress
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Stress Control and Problem Solving (cont’d)
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Proactive – Scheduled Assessment
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Ex: scheduling times to address progress and problems with spouse
every 3-6 months
Predictable times of change and stress
Stress Prevention
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Activity scheduling
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Track activities for a week, rank for pleasure and accomplishment
Schedule activities high in these areas
Important to know limits
Lifestyle choices and limit setting
Interpersonal and Social Rhythm Therapy
Combines IPT for unipolar depression with
behavioral strategies designed to regulate
daily routines and psychoeducation to
enhance treatment adherence.
Initial Phase
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Psychiatric and medical history
Events leading up to current and previous episodes
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Evidence of alterations or disruptions in routine or interpersonal
interactions
Interpersonal inventory
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Review of all important past and present relationships
Life circumstances
Quality of relationships
Listen for omissions/disruptions
Initial Phase
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Education on disorder
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Symptoms
Medications
Side effects, etc.
Role of circadian rhythm and rhythm disruption in disorder
Interpersonal and Social Rhythm Therapy, Frank et al. (2000)
Social Rhythm Metric (SRM)
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Record daily activities
How stimulating activities were
Daily mood
Intermediate Phase
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Social rhythm strategies
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Review first 3-4 weeks of SRMs to find rhythms that seem
unstable
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Encourage to work toward stabilization
Make goals for recovery/regulating rhythms
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Ex: sleep patterns
Graded
Range from short-term, intermediate, long-term
Also examine larger environmental stressors
Learn to adapt to changes in routine
At some point, patient will question the need for
stability…
Intermediate Phase
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Interpersonal strategies
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Identify problem area (grief, interpersonal role disputes, role
transition, interpersonal deficits)
Address the problem area
Attend to its role in promoting or disrupting social regularity
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Ex: loss of a loved one causes a disruption in social routine
Ex: fights with spouse lead to less sleep
Preventative Phase
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Decreases from weekly to monthly sessions
Can last 2 or more years
Continue evaluating what works best for patient
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Eliminate or change disruptive activities
Seek a stable pattern
Encouragement to address problems as they arise
May require crisis sessions as symptoms or
interpersonal dilemmas arise
Termination
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Over 4-6 monthly sessions
Review patient success
Discuss potential vulnerabilities
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Identify strategies for management of interpersonal difficulties
and symptom relapses
Encouragement about ability to use strategies
independently
Efficacy of CBT
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Lam et al. (2000)
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6 months, 12-20 sessions of CBT
Superior to outpatient treatment in reducing episodes and
coping with symptoms
Fava, Bartolucci, Rafanelli, & Mangelli (2001)
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CBT added to medication in patients with frequent relapses
Decreased residual symptoms and increase in time to relapse
Follow-up of patients at 2-9 years
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Of the 15 patients, only 5 experienced relapse
Swartz, Frank, & Kupfer (2006)
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Review of psychotherapies
Effect sizes of 0.32 to 0.45 (highest of all psychotherapies)
Cognitive strategies benefitted depressive symptoms
Behavioral strategies ameliorated manic symptoms
Efficacy of IPSRT
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Frank et al., 1997
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Compared traditional medication treatment to IPSRT
52 weeks
The 18 in IPSRT showed greater stability in routines
The 20 in medication only group showed no change in routines
Efficacy of IPSRT
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Frank et al., 2005
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175 participants in acute treatment, then maintenance treatment
(2 years)
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Those in IPSRT acute phase had longer intervals to relapse
during 2-year follow-up, regardless of maintenance treatment
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ICM + ICM
ICM + IPSRT
IPSRT + IPSRT
IPSRT + ICM
All in addition to pharmacotherapy
Also associated with a greater change in stability of routine
*Treatment during acute phase has a protective effect against
future episodes