16. Instability Model of BD
Vulnerability to
Bipolar Disorder
(Genetic-
Biological)
Medication
adherence
Disrupted social
(circadian)
rhythms
Sleep disruption
RELAPSE
Life events
Goodwin & Jameson 2007
17. Extensions of the cognitive models
of unipolar depression
‘Manic defence’ hypothesis –
psychodynamic model
Dysfunctional
cognitive style
Information
processing
Onset
Course
Expression
Above and
beyond genetic
predisposition
Life events
Current
environment
(supportive,
non-supportive
social)
Early
environment
(parenting and
maltreatment
histories)
18. Theory and science
Psychological
theories of
bipolar
Empirical
psychology
research
20. Negative thinking styles
Self blame
when things
go wrong
Self, others,
wider world in
negative light
Ruminate
when low
Risky sexual
behaviour, use
of alcohol,
street drugs,
other health
risks
Alloy et al 1999, Jones et al 2005, Thomas et al 2007
21. Positive thinking styles
Elevated
mood
Increased
alertness,
activity,
decreased
sleep
Interpret
these as
true self
Engage in
more
behaviors
(taking on
more,
resting less)
Increase
likelihood
of
hypomania
Jones et al 2006
22. Thinking styles between episodes
Similar to those in
episode (esp. depressive)
Unstable Tendency to fluctuate
Can change substantially
across episodes
Rapid changes in self-esteem
& mood
Contrasting thinking
styles at the same time
•When hypomanic see an
opportunity to more whilst also
recognizing a risk of becoming
ill
Jones et al 2006
23. Decision making and planning
Deficits in bipolar disorder
More likely to make
impulsive decisions and less
likely to take into account
future consequence of
decision making
Tendencies can interact with
the thinking styles noted
above and increase the risk
of further mood disorders
Clark et al 2002; Murphy et al 2001, 1999; Swann et al 2004
25. Life events & social support
Stressful life events
Prior to the onset of
first episode
Hypomanic/Manic
relapses
Depressive relapses
Positive social support more positive course
Negative support high EE – worse course
26. Methodological flaws in research
Methodological flaws in studies
Retrospective – ‘effort after meaning’ bias;
causes/consequences?
No control for mood state at time of reporting
Self-report measures and problem of mood bias
No inclusion of an appropriate control
No distinction between high/low relapses
Identified mood episode first, then stressor
Admission / start of treatment as beginning of episode
27. Types of life events and mania
Negative life events
Frequency before mania
Predicting manic relapse
Schedule disrupting life events
Goal attainment life events
28. Life events & relapse - mechanisms
Destabilizing
effects on
sleep
circadian rhythms
social rhythms
Goal attainment
or goal striving
hypersensitive
Behavioural
Activation System
- BAS
Kindling model
29. Social support & bipolar - mechanisms
Bipolar individuals
experience less support
than controls
Poor social support
predicts greater relapses
and longer time to
recover
High EE is predictive of a
worse outcome
EE studies
• ↑symptoms ↑perception
of negative family
environment
30. Parenting attachment – BD, UP, C
Parenting
Bipolar
compared
to …
Unipolar Control
Maternal
affection
Less cf.
control
Less
Paternal
affection
No
difference
Over control
by either
parent
No
difference
Attachment
Bipolar
compared
to …
Unipolar Control
Explicit
attachment
to mothers
Less cf.
control
Less
… paternal
attachment
No
difference
… peer
attachment
No
difference
Implicit
attachment
to fathers
Less
Rosenfarb, Becker, Khan 1994
31. Parenting attachment – BP, ADHD, C
Bipolars compared to … ADHD Controls
Parent-child interaction Greater impairment Greater impairment
Maternal warmth Less Less
Maternal tension/hostility Greater Greater
Paternal tension/hostility Greater Greater
Friends (youths) Fewer Fewer
Social skills Poorer Poorer
Geller et al 2000
32. Childhood maltreatment
Method
Childhood stressful
events
Both physical and
sexual abuse
N=155
Demographically
matched controls
Controlling for
Report biases
Genetic 3rd variables
Current depressive
and manic
symptomatology
Family history of mood
disorder
Separate associations
Independent (fateful,
uncontrollable) vs.
dependent
Occurred prior to vs.
after the age of the
first mood episode
Results
ONLY SPECIFIC EVENT
CATAGORIES
ASSOCIATED WITH
BIPOLARITY:
Childhood
maltreatment (PA & SA
combined)
Achievement failure
events
Grandin, Alloy and Abramson 2007
33. Manic defence hypothesis
Unstable Low
Fragile self esteem Grandiose defence
Threat
Helpless
Negative
Mania
Life events
Positive
cognitions on
explicit
measures
Depressive
cognitions on
implicit
measures
Abraham 1911,1927; Adler 1964; Neale 1988
35. Circadian rhythms
• Onset & Recurrence
• Why circadian rhythms might be relevant
• How they are measured and interpreted
• Evidence for them in bipolar disorder
• Lack of bridging model
• Disruption of psychological factors
• A model that may go some way to serving
these functions
36. BD is inherently a cyclical illness with a
typical course of relapse and recurrence
The Stanley Foundation Bipolar
Network: results of the naturalistic
follow-up study after 2.5 years of
follow-up in the German centres.
152 Germans, 2.5 year FU from hospitalisation
72% bipolar I; 25% bipolar II
42 years SD +/- 13.5
Onset 24.4 years SD +/- 10.9
40% rapid cycling
27% stable
56% recurrence
12.8% sub-syndromal symptoms
Dittmann S et al. 2002
37. Diagnostic criteria mania & depression
Importance of sleep and
behavioural disturbances as
symptoms in both types of
episode
Depression – insomnia &
hypersomnia, withdrawal
from activities and agitation
or retardation
Mania – decreased need for
sleep and increased goal-directed
and pleasurable (
but high risk activities)
38. Sleep
Sleep disturbance is
the ‘final-common
pathway’ for mania
Antidepressants &
lithium effects on
sleep
• Sleep phase
advance or
deprivation for
bipolar depressives
Search for biological
causes of circadian
disturbance is
common
Psychological causes
are less studied
Why do some not
suffer (e.g. shift
workers …)
39. Circadian rhythms basics
24.18 hours under controlled lighting
conditions
Sleep
Melatonin
Core body temperature
control
Cortisol
Consistent across all ages of
adults
Circadian rhythms seen in cellular activity,
body temperature, alertness, fluctuations in
hormone secretion
40. Circadian rhythms
Oscillators
Entrained by external
zeitgebers and zeitstorers
=<2 oscillators found in
studies of free runners
Under normal conditions
these cycles are synchronized
together
Under free running
conditions they move in and
out of phase with each other
41. Oscillators
Weak & strong oscillators
Strong
drives cycles which are less sensitive to
environmental manipulations
(REM sleep, body temperature, cortisol secretion,
urinary potassium secretion)
Weak
(rest/activity cycle, sleep/wake cycle, sleep
associated neuroendocrine activity)
Phase advance of the strong
oscillator is implicated in
depression
Suprachiasmatic nucleus function
42. Circadian rhythms in mania &
depression
Peripheral & core body
temperature, cortisol,
prolactin, growth hormone,
dopamine, beta-hydroxylase,
3-methoxy-4-
hydroxyphenylglycol
Body temperature rhythms in
manic and depressed
patients do not fit the
sinosoidal patterns of
normals – difference in
rhythmic stability
Cortisol, GH, cortisol levels
(see p94)
DA beta-hydroxylase –
circadian pattern lost in
mania but not depression
Also see 3M4HPG
43. Sleep activity cycle as a measure of
circadian disturbance
• Sleep disturbance in
– Mania
– Hypomania
– Depression
– Inter-episode
• State of trait?
• REM, non-REM or both
• See clinical relevance in
AJP article
• Circadian system
• Clinical implications
• http://ajp.psychiatryonli
ne.org/article.aspx?arti
cleID=99957#Bipolar%2
0Disorder%20and%20Sl
eep%20Disturbance%20
Often%20Coexist
44. Actigraphic assessment of sleep and
activity
• http://www.ncbi.nlm.nih.gov/pubmed/15762
859
• http://www.jad-journal.com/article/S0165-
0327(03)00055-7/abstract
• http://onlinelibrary.wiley.com/doi/10.1111/j.1
399-5618.2006.00329.x/abstract
50. Integration of the roles of circadian
and psychological factors in bipolar
disorder
51. Implications of an integrative
multilevel model of bipolar disorder
• Circadian instability outside of episodes
• Importance of early intervention
• Development of internal attribution measures
• Learning to reattribute fluctuations to external
causes
56. Intervention studies that incorporate coping
with bipolar prodromes as a therapy component
Study Subjects Therapy Control Duration Outcome
Identify prodromes and seek
help early: Perry et al 1999
N=69.
I = 63; II=6
Relapsed in previous 12
months
Training to identify
prodromes.
Rehearse action plan when
recognized.
TAU – drugs, monitoring,
support from key worker
7-12 individual sessions Over 18months:
- Significantly longer time
to relapse
- No beneficial effects on
depression
Schmitz et al 2002 N=46 with comorbid
substance misuse
Psychoeducation about BD
and substance dependence.
Identification of prodromes.
Coping skills training.
Four brief clinic visits for
medication monitoring,
discuss compliance, SEs,
substance use and mood
symptoms
16 individual sessions of 60
minute cognitive therapy
Over 3 months:
- No difference in
substance misuse
- Improvement in mood
symptoms (significant)
- Better attendance &
compliance (trend only)
FFT. Miklowitz et al 2000,
2003
N=101 type I
Episode previous 3 months
Radom allocation:
1/3 FFT
2/3 Rx & crisis management
Psychoeducation
Identify prodromal signs
Relapse prevention plans
Problem solving
Communication training
Medications
2 sessions of family
education
Crisis management
9 months of FFT Over 24 months FFT:
- Fewer relapses
- Longer time to relapse
- Better medication
compliance
- Greater reduction in
mood symptoms
Cognitive therapy. Lam et al
2005
N=103 type I
At risk of relapse
12-20 sessions CT with
psychoeducation
Psychiatric outpatients on
mood stabilizers
6 months therapy with 2
booster sessions
Over 30 months:
Fewer bipolar relapses
Fewer days in episode
Lower depression scores &
less fluctuation of manic
symptoms
Better coping strategies
FFT 2. Rea et al 2003 N=53 type I recently
hospitalized
21 group sessions:
psychoeducation,
prodromal signs, relapse
prevention, problem-solving,
communication
training
Individual sessions over 9
months. (12 weekly, 6
fortnightly, 3 monthly)
General psychoeducation.
9 months Over 24 months:
Fewer hospitalizations
Fewer relapses
No differences in time to
relapses
Psychoeducation. Colom et
al 2003.
N=100 stable euthymic I
N=20 type II
YMRS<6
HAM-D <8
Group psychoeducation
Weekly
21 sessions
Medication in OPC
20x 90 minute non-structured
group sessions
21x 90-minute group
sessions weekly of 9-12
patients
Over 24 months:
Fewer relapses
Increased time to episode
Fewer hospitalizations
Shorter length of
hospitalizations
57. Prodromes in bipolar
• Inherent problems in defining prodromes in
mental health
• Methodological issues
• Empirical findings
– Can bipolar patients report prodromes?
– Common prodromes
– Length od prodromal period
58. Coping in bipolar disorder
• Importance of coping
• Primary and secondary appraisal
• Functions of coping
• Coping with prodromes
59. Coping strategies for prodromes of mania
Ten most frequently
endorsed strategies
Good coping group (N=21)
(%)
Poor coping group (N=15)
(%)
Modifying excessive
behaviour
62 0
Engaging in calming
activities
48 13
Take extra time to rest 43 0
See a doctor 29 7
Take extra medication as
19 7
previously agreed
Enjoy the feeling of a high 5 20
Continued to move about 0 27
Did nothing 0 27
Spend more money 0 20
Find more to do 0 20
Lam & Wong 1997
60. Coping strategies for prodromes of depression
The seven most frequently
endorsed strategies
Good coping group (N=17)
(%)
Poor coping group (N=12)
(%)
Get oneself and keep busy 53 0
Get social support and
29 0
meet people
Distract myself from
negative thoughts
24 8
Recognize and evaluate
unrealistic thoughts
24 0
Stay in be and hope it will
go away
6 53
Take extra medication
without prescription
6 17
Do nothing 0 25
Lam & Wong 1997
62. PE: Elemental mechanisms
• Awareness of the disorder
• Early detection
• Adherence with treatment
63. PE: Secondary mechanisms
• Controlling stress & psychosocial factors
• Avoiding substance use and misuse
• Achieving regularity in lifestyle
• Preventing suicidal behaviour
• Role of individual psychological factors
64. PE: Desirable objectives
• Increasing knowledge and facing the
psychosocial consequences of past and future
episodes
• Improving social and interpersonal activity
between episodes
• Sub-syndromal symptoms and impairment
• Increasing well-being and improving the
quality of life
68. CBT Evidence
• Administered in euthymic state, works better
– Than waiting for treatment
– Sometimes better than treatment-as-usual
– Than brief psychoeducation
• However
– It depends on the outcome
– If CBT has lasting effects
74. CBT Euthymic: A new German RCT
Cognitive Behavioural Therapy Supportive Therapy
20 sessions (each 50 minutes) 20 sessions (each 50 minutes)
9 months 9 months
Psychoeducation Psychoeducation
Mood diary Mood diary
Relapse analysis and individual early
Focus on current problems
warning plan
Behavioural strategies Client-centered perspective
Cognitive strategies
Problem solving and communication
skills
Meyer & Hautzinger, in press, Psycholog Medicine
82. Mindfulness
• Tibetan - “Familiarization”
• Mind watching the mind
• Stopping dangerous thoughts and feelings
• Nipping things in the bud
• Neutral observer
• Paying attention in a particular way …
• … on purpose
• … in the present moment
• Moment by moment by moment by moment …
Philippe Goldin, Google Tech Talks, 2008
http://www.youtube.c Kabat-Zinn 1994 om/watch?v=sf6Q0G1iHBI&feature=related
83. MBSR
Formal
meditation
practice
Informal
meditation
practice
Yoga /
Stretching
Philippe Goldin, Google Tech Talks, 2008
http://www.youtube.com/watch?v=sf6Q0G1iHBI&feature=related
84. Clinical interventions incorporating
Buddhist Meditation
Mindfulness Based Stress Reduction (MBSR)
• Kabat-Zinn
Mindfulness Based Cognitive Therapy (MBCT)
• Segal, Teasdale, Williams
Dialectic Behaviour Therapy
• Linehan
Acceptance and Commitment Therapy (ACT)
• Hayes, Stroshal, Wilson
Philippe Goldin, Google Tech Talks, 2008
http://www.youtube.com/watch?v=sf6Q0G1iHBI&feature=related
89. Elements of DBT in bipolar
• Mindfulness
• Increasing your awareness
• Choosing how to act vs. react
• Surviving a crisis without making it worse
• Why we need emotions
• What to do about your emotions
• The challenges of anxiety disorders
• Radical acceptance
• Being more effective in relationships
• Skills for family members of people with bipolar
93. What is it?
1. Which therapy is the best?
2. Which elements of the therapy is best?
3. Is one therapy better for bipolar I or II?
4. Does this mean that all patients with bipolar
disorder should have one of these therapies?
96. Medication adherence
• Use of antidepressants
• Medication is usually necessary & effective
• 20-62% relapse despite medication
• 23-52% stop taking their medication
– Complexities of medication treatments
– Monitoring of long term medication
– Adjusting to taking medication chronically
– Dealing with side effects
– Reduce dysfunctional attitudes
97. Subsyndromal symptoms
• Early identification of prodromal symptoms
• Preventing the symptoms
• Managing the symptoms
• Managing comorbidity
– Anxiety disorders
– Alcohol & Drug misuse
– Personality disorder
– Medical disorders
– Psychosocial problems
100. Heuristic model of mania
S
Internal / external
Stress / Critical life events
Dysfunctional beliefs / Negative
attributions
Changes in daily life and
rhythms
Changes in medication
Interpersonal conflict
O
Arousal
Disruption in
sleep
R
Increase in activity
levels
Positive affect and/or
irritability
C
Positive reinforcement
Negative reinforcement
Feedback from others
Medication adherence fluctuates
Meyer (2008)
102. SYSTEM POSITIVE
REINFORCEMENT
THREAT / NEGATIVE
REINFORCEMENT
Controlling stimuli External & internal cues for
reinforcement / reward
Cues for missing reward or
punishment
Specific systems Goal directed:
• Social
• Achievement
• Sexual
Irritability / active
avoidance
General systems
Behavioural Activation System (BAS)
• Motor activation
• Incentive motivation
Depue & Iacono (1989); Depue & Zald (1993)
103. Behavioural Activation System
BAS
increased
BAS
decreased
MOOD Elevated &
euphoric
Empty,
depressed
MOTIVATION Hedonia Interest & lust Loss of interest,
anhedonic
Need for
novelty
Involvement in
many activities
Avoidance of
stimulation
AROUSAL Energy Tired,
exhausted
Sleep Hypersomnia,
day sleep
Thought Slow, problems
with decision
making
Depue & Iacono (1989)
104. BAS as Mania/Depression
MANIA DEPRESSION
MOOD Elevated &
euphoric
Empty, depressed
MOTIVATION Hedonia Interest & lust Loss of interest,
anhedonic
Need for
novelty
Involvement in
many activities
Avoidance of
stimulation
AROUSAL Energy Tired, exhausted
Sleep Hypersomnia, day
sleep
Thought Slow, problems
with decision
making
105. BAS core process of mania
[e.g. Depue & Zald, 1993; Alloy et al., 2006; Johnson, 2005)
106. BAS Core process of mania
[e.g. Depue & Zald, 1993; Alloy et al., 2006; Johnson (2005)
107. CBT model for bipolar
Medication Individual deficits Stress
Thoughts
Basco & Rush, 1996; Meyer & Hautzinger, 2004
Individual
resources
Instability of
biological
rhythms
Hypomanic /
manic, mixed or
depressive
Prodromal symptoms
symptoms
Emotions Behaviour
108. CBT Euthymic: A new German RCT
Randomisation
THERAPY
For 9 months
20 sessions
N=38 CBT
N=38 ST
FOLLOW UPS
(every 3/6 months)
B
A
S
E
L
I
N
t0 t1 t2 t3 t4 t5
Blind ratings
Meyer & Hautzinger, in press, Psycholog Medicine
109. CBT Euthymic: A new German RCT
Log Rank (Mantel-Cox) χ2 = 0.004, n.s.
Meyer & Hautzinger, in press, Psycholog Medicine
110. Euthymic state: Relapse prevention
• Psychosocial interventions – often help in
preventing relapses, especially depressive:
• But (1) – Number of prior episodes, comorbid
conditions, length of therapy
• But (2) – outcome of studies was ‘any relapse’ or
‘time to first relapse’
• But (3) – f(mania) > f(depression) ; low power
111. Bipolar depression
• Sub-syndromal symptoms significantly improve
due to psychotherapeutic intervention but not
psychoeducation
– [e.g. Castle et al., 2009; Lam et al., 2000, 2003; Meyer
& Hautzinger, in press; Miklowitz et al., 2003; Scott et
al., 2001]
• Bipolar depression remits faster when treated
with psychotherapy
– [STEP-BD; Miklowitz et al., 2007]
112. Mania & Mixed States
• There is no evidence yet for psychotherapy to work in
treating acute manic episodes
• No studies have looked at the efficacy of psychosocial
interventions for treating mixed episodes
• For subsyndromal and hypomanic symptoms there is:
– positive (Lam et al. (2000, 2003); Scott et al. (2001)) and
– negative evidence (Miklowitz et al. (2003))
113. Elements of psychological therapy
• Sufficiently long psychoeducation group
– CBT
– FFT
– IPSRT
• Relapse prevention is the main goal
114. Lack of evidence in …
• Comorbidity
• Bipolar II disorder
• Effectiveness of 3rd wave CBT
• Other psychological approaches
• Effectiveness of psychological therapies under
routine clinical practice
119. Positive Effects & Creativity
• Speed of thinking
• Range of emotions experienced
• Increased motivation and energy
• Flash of inspiration
Touched with Fire. Jameson 1996