Keywords: bipolar, cognitive, prodromal, adherence, family
Bipolar disorder, known colloquially as "manic-depression," is a heterogeneous affective disorder, apparently related to unipolar depression, but also involving varying degrees of euphoria, impulsivity, irritability, hyperactivity, agitation, and (sometimes) psychotic ideation. Less prevalent than unipolar depression, it strikes 0.8-1.6% of the adult population. Less is known about the incidence in childhood and adolescence, as the field is still trying to disentangle and otherwise understand the relationship between early onset bipolar disorder and childhood disorders such as conduct disorder (CD) and atten-tion-deficit/hyperactivity disorder (ADHD). Bipolar illness appears to be represented equivalently between the genders, and across ethnic groups (Bauer & McBride, 1996).
Symptom episodes involving depression and hypo-mania or mania often occur in cycles, thus causing serious, repeated psychological and general health problems for the sufferer. As the natural course of bipolar disorder often involves relapses, ongoing active treatment is necessary, preferably starting early in the course of the illness. When treatment is delayed, interrupted, or neglected, persons with bipolar disorder often experience a deteriorating course of their illness (Goldberg & Harrow, 1999). This involves shorter interepisode normality, greater duration of symptom episodes, and perhaps increased vulnerability to the triggering of mood swings with little environmental or biological provocation—a hypothesized phenomenon known as the "kindling effect" (Post & Weiss, 1989). At least half of all patients actively treated for bipolar illness do not respond quickly, or relapse after an initial, promising response. Thus, there is a pressing need to improve pharmacotherapeutic and psychotherapeutic interventions for this serious disorder.
Bipolar disorder is comprised of a number of subtypes, depending on the particular admixture of depression, hypo-mania, mania, and mixed episodes, as well as the duration and course of the symptom episodes (e.g., rapid-cycling). For example, a person diagnosed as "Bipolar II" does not have a history of full-blown mania, but rather has experienced at least one major depressive episode, and at least one hypomanic episode. Hypomania involves similar symptoms as mania—euphoria and irritability, decreased desire for sleep, racing thoughts and pressured speech, excessive goal-directed activities, increased distractibility, pursuit of high stimulation, decreased social judgment, and so on—but with lesser intensity and duration, and no sign of psychotic ideation. Those patients who have had full-blown manic episodes are designated as "Bipolar I," representing the individuals who are most at risk for serious interruptions in life functioning, damaged relationships, multiple losses, demoralization, and even suicide. For example, the conservative estimate of the proportion of patients with bipolar disorder who will ultimately die by suicide is 15% (Simpson & Jamison, 1999), a figure that takes into account those who are treated as well as those who are not. This ultimate hazard is worsened if the patients experienced mixed episodes, in which they have rapidly changing moods within the context of an overarching manic, impulsive, agitated presentation, and/or if they abuse psychoactive substances such as alcohol, cocaine, heroin, and others.
Prior to the development of mood stabilizers such as lithium, the standard treatments for bipolar disorder often involved the use of neuroleptics, electroconvulsive therapy, and institutionalization. As these approaches were largely ineffective, many individuals with bipolar disorder simply avoided treatment if they could, and their conditions deteriorated. The advent of lithium and its successors (e.g., Depakote, anticonvulsants, atypical antipsychotics) represented a significant improvement in the treatment of bipolar disorder, but there was still the problem of inconsistent medication adherence, toxicity, and symptom breakthrough. Thus, psychosocial treatment approaches came to the fore as a way to supplement the overall treatment of bipolar disorder. This makes intuitive sense—if we view bipolar disorder from a "diathesis-stress" model, medications are aimed at the biochemical diathesis, and the psychosocial interventions target the patients' "stress." For example, cognitive therapy (e.g., Newman, Leahy, Beck, Reilly-Harrington, & Gyulai, 2001) helps individuals with bipolar disorder to define and solve their problems more effectively, reframe life situations in a more constructive and less catastrophic way, improve self-efficacy so as to combat helplessness and hopelessness (and thus reduce the risk of suicide), and learn reliable self-instructional methods to moderate extreme moods and hyperarousal. Additionally, cognitive therapy has been shown to improve medication adherence, as the bipolar sufferers' misconceptions about their pharmacotherapy are addressed empathically, rationally, and with the aim of solving the problem (e.g., Lam et al., 2000; Scott, Garland, & Moorhead, 2001).
Another promising psychosocial model is focused family therapy (FFT; Miklowitz & Goldstein, 1997), an approach that reduces bipolar patients' stress by improving maladaptive family interactions that are associated with bipolar disorder. By working in session to reduce the frequency, intensity, and duration of hostile, accusatory, coercive communications between bipolar patients (many of whom feel overcontrolled, distrusted, and disrespected by their families) and their family members (many of whom feel frightened, frustrated, and depleted in the face of the chaotic life of their family member with bipolar disorder), practitioners of FFT can improve the quality of life of all parties in the family. Goals include improving intrafamilial empathy, cooperation, and problem-solving, and decreasing conflicts, blaming, shaming, and related forms of acting out. Presumably, bipolar patients' participation in pharmacother-apy is enhanced when adherence is no longer perceived as central to the power struggle within the family.
Another psychosocial model combines the tenets of interpersonal therapy (IPT) with a methodology to regulate the biopsychosocial rhythms of the bipolar patients— interpersonal, social-rhythm therapy (IP-SRT; Frank et al., 1994). As individuals with bipolar disorder are very sensitive to changes in their sleep-wake cycle (e.g., with the risk of mania increasing with disruptions in normal sleep), IP-SRT addresses the patient's world of relationships. The chief hypothesis is that by improving the stability of the personal life of the individual with bipolar disorder, there will be less of the sort of conflict and turmoil that will increase stress, cause loss of sleep, and exacerbate impulsivity. Thus, the bipolar patient will be more apt to maintain mood states within normal limits, provided that medication adherence is optimal.
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