Day 48: Psychotherapy in Bipolar Disorder

Today we are continuing our current theme of bipolar disorder. We now have enough background to start discussing treatment and management. Pharmacological treatment is essential for the treatment of bipolar disorder, but we are first going to take one day to talk about the nonpharmacologic interventions and management of these patients. We will discuss a few interventions that have a strong evidence base to include psychoeducation, social rhythm therapy, CBT, and family-focused therapy.


Today's Content Level: Intermediate; Advanced



A QUICK WORD ON MEDS


Drug treatment is the mainstay of therapy for mania, hypomania, and bipolar depression. Having said this, there are non pharmacological strategies that can improve the chances of recovery, reduce relapse, and improve the quality of life of patients with bipolar disorder.


•Focus should be on treating and stabilizing the acute phase of the illness and afterwards can create a treatment strategy that involves maintenance treatment and prevention of relapse.


•Optimum management is the integration of pharmacotherapy with targeted psychotherapy.



PSYCHOEDUCATION


•Educate patient and family about the illness to include the typical course/pattern of symptoms, episode triggers, and stressors that put them at higher risk of relapse.


•Education must be continued throughout the illness as their insight may vary considerably during different phases of the illness.


•A primary goal of psychoeducation is to enhance treatment adherence.



INTERPERSONAL AND SOCIAL RHYTHM THERAPY (IPSRT)


Bipolar disorder is characterized by frequent recurrences/relapses. These are often related to:

  • Noncompliance with medications

  • Stressful life events

  • Social rhythm disruption / Circadian rhythm disruption


Interpersonal and social rhythm therapy (IPSRT) was designed to address these problem areas.


•The most influential regulator of the circadian rhythm is the rising and setting of the sun, but our modern societies' rhythm is no longer solely governed by natural light due to artificial light sources. This leads to an increased importance of social factors that impact our circadian rhythm. These factors include timing of meals, work schedules, schedules of other family members, timing of exercise, and even when we watch TV and use our devices.


•At the core of the IPSRT theory is that we are all susceptible to the disruptive effects of changes in any of these social cues, but those who are at higher risk for mood disorders (particularly bipolar disorder) are even more susceptible. This may lead to full manic or depressive episodes.


Treatment involves four phases:

  1. Initial Phase -> Determine their pattern/associations between social routine disruptions and affective episodes. Psychoeducation about the importance of routines. Also one of four interpersonal areas is chosen to be worked on (grief, role transitions, role disputes, interpersonal deficits).

  2. Intermediate Phase -> Establish and implement regularity to social rhythms and routines. Also provide intervention to the interpersonal area of interest from step 1.

  3. Maintenance Phase -> Reinforce the techniques learned earlier in treatment in order to maintain social rhythms and positive interpersonal relationships.

  4. Final Phase -> Involves termination in which sessions are gradually reduced in frequency.



COGNITIVE BEHAVIORAL THERAPY (CBT)


•This form of psychotherapy combines cognitive therapy with behavioral therapy. The basic idea is that our thoughts (cognitions), behaviors, and emotions are all interrelated, so that if we change one then we change the rest.


•CBT is an evidenced based treatment for a number of disorders including major depression, bipolar disorder, panic disorder, social anxiety, generalized anxiety, OCD, phobias, PTSD, eating disorders, psychotic disorders, substance abuse, personality disorders, insomnia, and chronic pain.


CBT for bipolar disorder often focuses on:

  • Psychoeducation and acceptance of diagnosis.

  • Regular "check-ins" or self monitoring of mood.

  • Cognitive restructuring (correcting thinking mistakes).

  • Problem solving.

  • Stabilizing routines.


•CBT was discussed in detail during the depressive theme. For a full discussion of the theory and logistical application see that post.



FAMILY-FOCUSED THERAPY (FFT)


•Family-focused therapy (FFT) is an evidence-based intervention for adults and children with bipolar disorder (BD) and their caregivers. This type of intervention is commonly given after an illness episode or hospitalization.


The treatment consists of conjoint sessions of:

  • Psychoeducation regarding bipolar illness.

  • Communication enhancement training.

  • Problem-solving skills training.


•You are probably sensing a general theme here but treatment is focused on helping the patient and the family accept the diagnosis and the notion of vulnerability to future episodes. It also stresses the necessity of mood-stabilizing medications for symptom control.


•It is also designed to help recognize and learn to cope with stressful life events that may trigger mood recurrences.


•From a family perspective it attempts to reestablish functional family or marital relationships after an illness episode and increase communication between all parties. The more the family is involved the better, as they tend to notice symptoms earlier and can help limit access to finances or other triggers for reckless behavior.



CONCLUSION


I hope you found this overview helpful. Next lesson we will jump right into pharmacological management of bipolar disorder.


Resources for this article include Pocket Psychiatry, PubMed, and NCBI.

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