Bipolar Psychopathology

BIPOLAR DISORDER CREATIVITY, ENERGY, SENSITIVITY, MANIA, DEPRESSION, SUICIDE AN OVERVIEW OF THE ILLNESS: CARDINAL FEATURES, DIFFERENTIAL DIAGNOSES, ETIOLOGY,SPIRITUAL IMPLICATIONS

Christy Green, MS, NCC Mark Hattendorf Mary Jeppsen LAC, LAMFT Regent University Advanced Psychopathology

Bipolar Disorder is a mood disorder characterized by manic, depressive or mixed episodes.  Bipolar I (DSM Criteria) Characterized by one or more manic episodes severe enough to warrant hospitalization, change functioning, impair occupation  Psychosis may be present  Affects 0.4-1.6% of population 

Bipolar I continued

Occurs equally among men and women  Characterized by mixed episode( manic and depressive episode co-occurring within 7 days)  Recurrent  May be rapid-cycling 

Bipolar II diagnosis predisposes emergence of Bipolar I (Durand & Barlow,2006)  Bipolar II : DSM Criteria Characterized by at least one hypomanic (elevated , expansive, irritable mood) episode lasting for at least 4 days  Episode is less intense than a manic episode for Bipolar I.  Characterized by one or more episodes of major depression. 

Bipolar II continued

Affects 0.5% of population  More common in women than men  May be rapid-cycling  (Rivas-Vasquesz, Johnson, Rey, Blais,& Rivas-Vasquez, 2002) 

Etiology   

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Genetic influence: first degree biological relatives (DSMIV) Deficit in cortisol inhibitory system (Johnson,S., Roberts, J., 1995) Associated with stress/ trauma (stressful event initiates pathophysiological process and pattern becomes repetitive) (Wright, Lam, Newsom-Davis, 2005).

Associated with elevated dysfunctional cognitions related to achievement and goal-striving (Wright et al., 2005) Perpetuated by disturbance of circadian rhythm(Wright et al., 2005)

Course of illness      

Average onset age 20 Recurrent manic episodes in 90% Episodic interval increases with age 60% experience interpersonal and occupational problems Psychosis may develop after manic episodes (DSM-IV)

Suicidality    

Lifetime risk 17% for Bipolar I (Durand & Barlow, 2006) Lifetime risk 24% for Bipolar II (Durand & Barlow, 2006) Risk of suicide higher than for any other mental disorder (Goodwin & Jamison, 1990).

Rates of completed suicide 4X higher than for Major Depressive Disorder (Durand & Barlow, 2006); 10%-15% for Bipolar I (DSM-IV)

Differential Diagnoses  Cyclothymic

Disorder

Chronic disorder lasting 2 years with hypomania and depression  During first 2 years, no manic or mixed episodes  0.4-1.0% of population affected (RivasVasquez et al., 2000)  15-50% chance of developing Bipolar Disorder(APA, 2000) 

Differential Diagnoses ď Ź Bipolar

Disorder NOS-A Bipolar

Spectrum disorder where hypomanic symptoms and depressive symptoms are present, but all criterion are not met ď Ź Seasonal Affective Disorder-Bipolar depressive and manic episodes occur during specific seasons (Mostly manifested as Winter Depression), (Durand & Barlow, 2006).

Other Associated Mental Disorders   

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Anorexia Nervosa, Bulimia Nervosa, ADHD, Panic Disorder, Social Phobia (DSM-IV).

Bipolar Disorder may be associated with substance abuse disorders (DSM-IV).

Also associated with school truancy, school and occupational failure, divorce, episodic antisocial behavior (DSM-IV) Manic episodes , psychotic episodes may increase incidence of child and spousal abuse, violent behaviors (DSM-IV).

Childhood/ Adolescent Onset

Often misdiagnosed or undiagnosed (Faedda, Balessarini, Glovinski & Austin, 2004, McNicholas,F., Baird, G., 2000). ď Ź

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A complete family history will aid in the accurate diagnosis of Childhood Bipolar Disorder because multigenerational history of affective disorders is a predictor. (Faedda, Balessarini, Glovinski & Austin, 2004).

Before age 9, children present with sleeping difficulties, impulsivity, over-activity, inattention, reduced frustration tolerance, explosive angry outbursts, mood instability, irritability Non-episodic, chronic presentation

Childhood Onset Symptomology (continued)

Euphoria and grandiosity rare in children  Depression and irritability common at onset  Associated with aggression and suicide  10%-15% of adolescents with Bipolar II who have recurrent Major Depressive episodes will develop Bipolar I (DSM-IV). 

Childhood Bipolar Disorder (continued)

 Comorbidity is a concern  Childhood Bipolar Disorder often overlaps with, ADHD, Major Depressive Disorder, Anxiety Disorders including OCD, Conduct Disorders and Dysthymia (Papolos & Papolos, 1999).  Psychopharmacology for related illnesses can prove to heighten the course of Bipolar Disorder (Stimulants).  Comorbidity with ADHD is 57% - 98% (McNicholas, F., Baird, G., 2000).

Psychoparmacology     

Limbic system and associated regions are locus of dysfunction (Rivas-Vasquez et al, 2002).

Norepinephrine, dopamine, and serotonin transmission are targeted.

GABA, the main inhibitory transmitter in brain, targeted Disruption in calcium ion levels targeted Drugs which effect these systems have proven to be effective in the treatment of Bipolar mania.

Pharmacotherapy  Lithium

(Lithobid)

Affects neurotransmission, impacts several brain function systems, controls acute manic episodes  Levels must be monitored carefully especially in relation to other drug interactions 

Pharmacotherapy continued

 Anticonvulsants  Valproate- anti-seizure medication which treats mania with less side effects than lithium and effective with rapid-cycling manic episodes.

(Depakote)  Carbamazepine- (Tegretol) no FDA approval for mania yet  New Anticonvulsants: Gabapentin (Neurontin), Topimirate  Lamotrigine(Lamictal)

Pharmacotherapy continued

 Calcium

Channel Blockers  Atypical Antipsychotics: Olanzipine (Zyprexa)  Clozapine (Clozaril)  Quetiapine and Ziprasidone. 

Pharmacotherapy continued

 Benzodiazepines:

Contribute to anti-manic response by controlling behaviors  Lorazepam(Ativan) and clonazepam (Klonopin)  Used in addition to mood stabilizers 

Best Practices: Cognitive Behavioral Therapy 

National Institute for Clinical Excellence (NICE) Guidelines for Bipolar Disorder (NICE, 2006) -Structured psychological interventions focusing on relapse prevention and enhanced coping, such as CBT, are effective treatments.

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Associative mechanisms accumulate through repeated mood episodes, causing future episodes to be more easily triggered (Barnard, 2004; Jones, 2001), thus implementing CBT interventions earlier in the course of illness prior to strong associated links becoming established, may result in a more powerful and improved outcome (Jones & Burrell-Hodgson, 2008).

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Significant improvement in mania relapse rates and functional outcomes for participants who received an early warning signs and coping skills intervention which included early help-seeking behavior (Perry, Tarrier, Morriss, McCarthy, & Limb, 1999).

Best Practices: CBT (continued) ď Ź

Utilizing a comprehensive CBT intervention (Lam, Hayward, Watkins, Wright, & Sham, 2005; Lam et al., 2003), participants demonstrated increased mood stability, improved social functioning, few bipolar episodes. And improved coping skills over a 12 month follow up period. While differential improvements in relapse rates were not sustained at the 2-year follow up, the other above listed gains had been maintained.

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When CBT was compared with the use of Psychoeducational interventions to treat bipolar disorder (Zaretsky, Lancee, Miller, Harris, & Parikh, 2008), CBT participants experienced a 50% reduction in # of depressed days, and 80% of participants were able to have their anti-depressant medication decreased. Only 25% of participants in the PE group were able to experience decreased intensity of anti-depressant medication therapy.

Best Practices: Interpersonal Therapy and Interpersonal and Social Rhythm Therapy 

IPT has it’s foundational theoretic roots in attachment and object relations theory (Sullivan 1968; Rogers, 1951; Erickson, 1968; Bowlby, 1988; Brisch, 2002) emphasizing what people do to manage change, constancy and separation anxiety in interpersonal relationships.

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Object relations theory posits that attachment to internalized parental figures (albeit secure or maladaptive) form relational templates (Farber & Geller, 1994) from which clients form working models to pattern representations of self and others.

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IPT enters the relational template/schema, (as it is occurring) by focusing on the repetitive transactional patterns or process that happens between client and therapist which is a transactional pattern of early learned attachment patterns (Teyber, 2006).

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IPT seeks to modify schemas and internalized splits by providing a Corrective Emotional Experience ( Bandura, 1997) an in vivo relearning by contrast.

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IPSRT adds to IPT by introducing the stabilizing of circadian rhythms (Jones, 2001) through cognitive training and social patterning.

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IPSRT ( Frank, 2005) is a multimodal approach that trains the client the importance of adhering to prescribed medications.

Spiritual Implications and Interventions: Theophostic Ministry (Smith, 2005) 

Theos= God

Phos=Light

What is God’s light = Jesus

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Ed Smith stumbled upon Theophostic Ministry because of a lack of success in sexual abuse groups he was leading. It was born of frustration.

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Instead of trying to cognitively introduce truth to their irrational beliefs, or instead of trying to provide the corrective emotional experience himself, he asked the Lord to communicate truth to the survivors and have Jesus provide the corrective emotional experience himself.

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The three necessary components of Theophostic Prayer Ministry:

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1) The emotional echo: borrowing past pain and adding it to present

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2) The original memory picture: client must be “in the memory”

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3) The original lie: what painful cognitions were formulated in the trauma

An Overview of the Theophostic Procedure. 

1) Prepare the client and pray: explain to the client what is going to happen to them

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2) Identify the memory clues: listen to the clients story for clues – this project is __

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3) Identify their presenting emotions: use and stir, as a jumping off to historical ones

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4) Find the memory picture: follow the emotions to original matching memory picture

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5) Identify the original lie: listen to phrases or themes while client is in the memory

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6) Rate how the lie feels: does it feel true that you will never succeed in the PH.D.

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7) Stir up the darkness: feel that failure of not succeeding in getting a PH.D.

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8) Receive the truth: can you perceive the presence of Jesus, what does he say

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9) Remove the clutter: vows, hate, unforgiveness, warfare, dissociation, Freudian D’s

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10) Follow Jesus to the next memory: continue down the road

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11) Pray for affirmation and blessings: important to fill the void left and seal the work

Concluding statements ď Ź

This presentation provided an overview of essential elements and cardinal features of bipolar disorder including:

1) Diagnostic Categorization and Criteria 2) Etiology 3) Differential Diagnosis and Comorbidity 4) Best Treatment Practices ď Ź

The DSM-IV-TR Case Book vol. 2: Experts tell how they treated their own patients (2006), lists several case studies under mood disorder in which treatments range from the traditional medical model medications to more recent combined multimodalities. Being at the preeminent Christian University, we added the spiritual component as a possible consideration for treatment.

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If you notice the organization of this presentation you will find that the outline follows a continuum starting at the purely biological, statistical aspects of bipolar disease on to the cognitive aspects, then the mind or soul and then finally to the social and spiritual implications. It is our hope that the participants in this discussion will not find a stopping point on this continuum on which to theoretically rest; rather it is with the hope that every member will be challenged to find a point which best suits the particular needs of the client in order to ameliorate the pain and suffering inherent in this disease.

References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text revision). Washington, D.C.: Author.

American Psychiatric Association. (2006). Case book volume 2: The experts tell how they treated their own patients. Washington, D.C.: Author.

Bandura, A. (1997). Self-Efficacy: The exercise of self control. New York, New York: Freeman.

Bowlby, J. (1988). A secure base. New York, New York: Basic Books.

Brisch, K. H. (2002). Treating attachment disorders: From theory to therapy. New York, New York: Guilford.

Barnard, P. (2004). Bridging between basic theory and clinical practice. Behaviour Research and Therapy, 42, 977-1000 Durand, V.M. & Barlow, D.H.( 2010). Essentials of Abnormal Psychology (5th edition).

Belmont, California: Wadsworth.

Erickson, E. (1968). Childhood and Society. (2nd ed.). New York, New York: Norton.

Faedda, G. L., Balessarini, I., Glovinski, R., Austin,N.(2004). Pediatric bipolar disorder: Phenomenology and course of illness. Bipolar Disorders,6,305-313. BlackwellMunksgaard.

Farber, B., & Geller, J. (1994). Gender and representation in psychotherapy.

Psychotherapy, 31, 318-326.

Frank, E. (2005). Treating bipolar disorder: A clinician’s guide to Interpersonal and Social Rhythm Therapy. New York: Gilford Press.

Goodwin, F.K., & Jamison, K.R. (1990). Manic depressive illness. New York: Oxford University Press.

Johnson, S.L. , & Roberts, J.E. (1995). Life events and Bipolar disorder: Implications from biological theories. Psychological Bulletin,117,434-449.

References (continued) Jones, S. (2001). Circadian rhythms, multilevel models of emotion and bipolar disorder: An initial step towards integration? Clinical Psychology Review, 21, 1193-1209.

Lam, D., Hayward, P., Watkins, E., Wright, K., & Sham, P. (2005). Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after 2 years.

American Journal of Psychiatry, 162, 324-329.

Lam, D., Watkins, E., Hayward, P., Bright, J., Wright, K., Kerr, N., Parr-Davis, G., & Sham, P. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60, 145-152.

McNicholas, F. & Baird, G. (2000). Early onset bipolar disorder and adhd: Diagnostic confusion due to comorbidity .Clinical Child Psychology and Psychiatry,5,595-607.

NICE. (2006). Clinical guidelines for bipolar disorder. London: National Institute for Clinical Excellence.

Papolos,D. & Papolos, J., (1999). The bipolar child. New York, New York: Broadway Books.

Perry, A., Tarrier, N., Morriss, R., McCarthy, E., & Limb, K. (1999). Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain treatment. British Medical Journal, 318, 149-153.

Rivas-Vasquez, R., Johnson, S. , Rey, Gustavo, Blais, M. & Rivas-Vasquez, A.(2002).

Current treatments for bipolar disorder: A review and update for psychologists.

Professional Psychology: Research and Practice,33,2,212-223. The American Psychological Society, Inc. Rogers, C. (1951). Client centered therapy. Boston, MA: Houghton Mifflin.

Smith, E. M. (2005). Beyond tolerable recovery. Campbellsville, KY. New Creation.

Sullivan, H. S. (1968). The interpersonal theory of psychiatry. New York, New York: Norton.

References (continued) Teyber, E. (2006). Interpersonal process in therapy: An integrative model. Belmont, CA: Thomson Brooks/Cole.

Wright, K., Lam, D. , Newsom-Davis, I. (2005). Induced mood change and dysfunctional attitudes in remitted bipolar I affective disorder. Journal of Abnormal Psychology,114 (4),689-696.

Zaretsky, A., Lancee, W., Miller, C., Harris, A., & Parikh, S. (2008). Is cognitivebehavioural therapy more effective than psychoeducation in bipolar disorder? The Canadian Journal of Psychiatry, 53 (7), 441-448.