SlideShare a Scribd company logo
1 of 121
Download to read offline
Mania 
A psychological perspective 
Dr. Nick Stafford
Mania - a psychological perspective (talk 2)
THE BIOLOGY OF THE PSYCHOLOGY
Some putative biological mechanisms 
Cortisol/HPA/HPT 
Sleep & circadian 
dysregulation 
Neural 
degeneration 
Oxidative stress 
Inflammatory 
processes 
Apoptosis 
Prefrontal 
dysfunction 
Amygdala / 
hippocampal 
dysfunction 
Affect regulation 
activations
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
Andreassan
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
INFLAMMATORY CYTOKINES
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
Psychosocial risk factors 
Illness 
Life events 
Current 
environment 
Early 
environment
Instability Model of BD 
Vulnerability to 
Bipolar Disorder 
(Genetic- 
Biological) 
Medication 
adherence 
Disrupted social 
(circadian) 
rhythms 
Sleep disruption 
RELAPSE 
Life events 
Goodwin & Jameson 2007
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)
Theory and science 
Psychological 
theories of 
bipolar 
Empirical 
psychology 
research
THINKING STYLES
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
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
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
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
LIFE EVENTS
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
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
Types of life events and mania 
Negative life events 
Frequency before mania 
Predicting manic relapse 
Schedule disrupting life events 
Goal attainment life events
Life events & relapse - mechanisms 
Destabilizing 
effects on 
sleep 
circadian rhythms 
social rhythms 
Goal attainment 
or goal striving 
hypersensitive 
Behavioural 
Activation System 
- BAS 
Kindling model
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
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
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
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
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
DYSREGULATION OF THE 
CIRCADIAN RHYTHMS
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
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
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)
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 …)
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
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
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
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
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
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
How might circadian disruption lead to 
bipolar symptoms
SELF-ESTEEM
Disturbed psychological functioning in 
bipolar disorder
Variability in the impact of circadian 
disruption
Kindling theory and the impact of life 
events
Integration of the roles of circadian 
and psychological factors in bipolar 
disorder
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
Internal attributions
CLINICAL PSYCHOLOGICAL 
INTERVENTIONS
There is Clinical Evidence for … 
CBT FFT 
IPSRT PE
EARLY WARNING SIGNS & COPING 
STRATEGIES
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
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
Coping in bipolar disorder 
• Importance of coping 
• Primary and secondary appraisal 
• Functions of coping 
• Coping with prodromes
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
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
PSYCHOEDUCATION
PE: Elemental mechanisms 
• Awareness of the disorder 
• Early detection 
• Adherence with treatment
PE: Secondary mechanisms 
• Controlling stress & psychosocial factors 
• Avoiding substance use and misuse 
• Achieving regularity in lifestyle 
• Preventing suicidal behaviour 
• Role of individual psychological factors
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
Prodrome detection 
Perry 1999
Psychoeducation 
Colom 2003
Psychoeducation Evidence 
[Colom et al., 2009, Brit J Psych]
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
Cognitive therapy 
Lam 2005
CT
CT
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
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
IPSRT
IPSRT
FAMILY APPROACHES
FFT
FFT & IPSRT
MINDFULNESS
Where is your mind now?
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
MBSR 
Formal 
meditation 
practice 
Informal 
meditation 
practice 
Yoga / 
Stretching 
Philippe Goldin, Google Tech Talks, 2008 
http://www.youtube.com/watch?v=sf6Q0G1iHBI&feature=related
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
Mania - a psychological perspective (talk 2)
DBT
DBT’s five core modules / skills 
• Mindfulness 
• Distress tolerance 
• Emotion regulation 
• Interpersonal effectiveness 
• Self management
Mania - a psychological perspective (talk 2)
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
Evidence for DBT in Bipolar 
Goldstein et al 2007
Mania - a psychological perspective (talk 2)
Summary of psychosocial interventions
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?
Treatment 
• Historical management to prevent bipolar 
relapse 
• Psychological treatment
Biopsychosocial approaches 
• Psychoeducation 
• IPSRT 
• DBT 
• CBT
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
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
PSYCHOLOGICAL PATHWAYS TO 
MANIA
DYSFUNCTIONAL BELIEFS
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)
OVERSENSITIVITY OF THE 
BEHAVIOURAL ACTIVATION SYSTEM
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)
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)
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
BAS core process of mania 
[e.g. Depue & Zald, 1993; Alloy et al., 2006; Johnson, 2005)
BAS Core process of mania 
[e.g. Depue & Zald, 1993; Alloy et al., 2006; Johnson (2005)
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
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
CBT Euthymic: A new German RCT 
Log Rank (Mantel-Cox) χ2 = 0.004, n.s. 
Meyer & Hautzinger, in press, Psycholog Medicine
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
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]
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))
Elements of psychological therapy 
• Sufficiently long psychoeducation group 
– CBT 
– FFT 
– IPSRT 
• Relapse prevention is the main goal
Lack of evidence in … 
• Comorbidity 
• Bipolar II disorder 
• Effectiveness of 3rd wave CBT 
• Other psychological approaches 
• Effectiveness of psychological therapies under 
routine clinical practice
COGNITIVE CHANGES
Mania - a psychological perspective (talk 2)
Mania - a psychological perspective (talk 2)
OXIDATIVE STRESS
Positive Effects & Creativity 
• Speed of thinking 
• Range of emotions experienced 
• Increased motivation and energy 
• Flash of inspiration 
Touched with Fire. Jameson 1996
Relaxation Training
Acknowledgments 
• Thomas Meyer. Newcastle University.

More Related Content

What's hot

Models of mental health & illness
Models of mental health & illnessModels of mental health & illness
Models of mental health & illnessSudarshana Dasgupta
 
PHENOMENOLOGY OF DELUSION
PHENOMENOLOGY OF DELUSIONPHENOMENOLOGY OF DELUSION
PHENOMENOLOGY OF DELUSIONFaisal Shaan
 
Treatment resistant schizophrenia & Treatment resistant depression
Treatment resistant schizophrenia & Treatment resistant depressionTreatment resistant schizophrenia & Treatment resistant depression
Treatment resistant schizophrenia & Treatment resistant depressionEnoch R G
 
Pathophysiology: Introduction to Neuropsychiatry
Pathophysiology: Introduction to Neuropsychiatry Pathophysiology: Introduction to Neuropsychiatry
Pathophysiology: Introduction to Neuropsychiatry Brian Piper
 
Neurobiology of OCD
Neurobiology of OCDNeurobiology of OCD
Neurobiology of OCDCijo Alex
 
ICD 11 proposed changes - A New Perspective On An Old Dream
ICD 11 proposed changes - A New Perspective On An Old DreamICD 11 proposed changes - A New Perspective On An Old Dream
ICD 11 proposed changes - A New Perspective On An Old DreamMohamed Sedky
 
Schizophrenia & other psychotic disorder
Schizophrenia & other psychotic disorderSchizophrenia & other psychotic disorder
Schizophrenia & other psychotic disorderHussein Ali Ramadhan
 
Psychopathology depression
Psychopathology depressionPsychopathology depression
Psychopathology depressionehab elbaz
 
MOTIVATION ENHANCEMENT THERAPY
MOTIVATION ENHANCEMENT THERAPYMOTIVATION ENHANCEMENT THERAPY
MOTIVATION ENHANCEMENT THERAPYssompur
 
Anxiety Disorders
Anxiety DisordersAnxiety Disorders
Anxiety Disordersvelspharmd
 
Introduction to psychiatry
Introduction to psychiatryIntroduction to psychiatry
Introduction to psychiatryPk Doctors
 
ADHD - Attention Deficit Hyperactivity Disorder
ADHD - Attention Deficit Hyperactivity DisorderADHD - Attention Deficit Hyperactivity Disorder
ADHD - Attention Deficit Hyperactivity DisorderNaveen Kumar Cheri
 
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)Sytematic treatment enhancement program for bipolar disorder(step bd) (1)
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)Dr Wasim
 
Interpersonal psychotherapy final
Interpersonal psychotherapy finalInterpersonal psychotherapy final
Interpersonal psychotherapy finalTeo Meijun
 
Clinical features and Management of Schizophrenia
Clinical features and Management of SchizophreniaClinical features and Management of Schizophrenia
Clinical features and Management of SchizophreniaDr Kaushik Nandy
 

What's hot (20)

Models of mental health & illness
Models of mental health & illnessModels of mental health & illness
Models of mental health & illness
 
PHENOMENOLOGY OF DELUSION
PHENOMENOLOGY OF DELUSIONPHENOMENOLOGY OF DELUSION
PHENOMENOLOGY OF DELUSION
 
Treatment resistant schizophrenia & Treatment resistant depression
Treatment resistant schizophrenia & Treatment resistant depressionTreatment resistant schizophrenia & Treatment resistant depression
Treatment resistant schizophrenia & Treatment resistant depression
 
Pathophysiology: Introduction to Neuropsychiatry
Pathophysiology: Introduction to Neuropsychiatry Pathophysiology: Introduction to Neuropsychiatry
Pathophysiology: Introduction to Neuropsychiatry
 
Neurobiology of OCD
Neurobiology of OCDNeurobiology of OCD
Neurobiology of OCD
 
ICD 11 proposed changes - A New Perspective On An Old Dream
ICD 11 proposed changes - A New Perspective On An Old DreamICD 11 proposed changes - A New Perspective On An Old Dream
ICD 11 proposed changes - A New Perspective On An Old Dream
 
Schizophrenia & other psychotic disorder
Schizophrenia & other psychotic disorderSchizophrenia & other psychotic disorder
Schizophrenia & other psychotic disorder
 
Psychopathology depression
Psychopathology depressionPsychopathology depression
Psychopathology depression
 
MOTIVATION ENHANCEMENT THERAPY
MOTIVATION ENHANCEMENT THERAPYMOTIVATION ENHANCEMENT THERAPY
MOTIVATION ENHANCEMENT THERAPY
 
Conversion Disorder
Conversion DisorderConversion Disorder
Conversion Disorder
 
Cbt -Ocd
Cbt -OcdCbt -Ocd
Cbt -Ocd
 
Anxiety Disorders
Anxiety DisordersAnxiety Disorders
Anxiety Disorders
 
Introduction to psychiatry
Introduction to psychiatryIntroduction to psychiatry
Introduction to psychiatry
 
ADHD - Attention Deficit Hyperactivity Disorder
ADHD - Attention Deficit Hyperactivity DisorderADHD - Attention Deficit Hyperactivity Disorder
ADHD - Attention Deficit Hyperactivity Disorder
 
Neurobiology of depression
Neurobiology of depressionNeurobiology of depression
Neurobiology of depression
 
Bipolar Disorder
Bipolar DisorderBipolar Disorder
Bipolar Disorder
 
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)Sytematic treatment enhancement program for bipolar disorder(step bd) (1)
Sytematic treatment enhancement program for bipolar disorder(step bd) (1)
 
Interpersonal psychotherapy final
Interpersonal psychotherapy finalInterpersonal psychotherapy final
Interpersonal psychotherapy final
 
Mood disorders slide
Mood disorders slideMood disorders slide
Mood disorders slide
 
Clinical features and Management of Schizophrenia
Clinical features and Management of SchizophreniaClinical features and Management of Schizophrenia
Clinical features and Management of Schizophrenia
 

Viewers also liked

Pregnancy as a psychological event
Pregnancy as a psychological event Pregnancy as a psychological event
Pregnancy as a psychological event Mohammed Khalifa
 
Psychological changes of pregnancy
Psychological changes of pregnancyPsychological changes of pregnancy
Psychological changes of pregnancyReynel Dan
 
Challenges in obstetrics and gynaecology psychological perspective
Challenges in obstetrics and gynaecology   psychological perspectiveChallenges in obstetrics and gynaecology   psychological perspective
Challenges in obstetrics and gynaecology psychological perspectivekumar mahi
 
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTH
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTHNURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTH
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTHfcohen25
 
Postpartum psychiatric disorder
Postpartum psychiatric disorderPostpartum psychiatric disorder
Postpartum psychiatric disorderNur Liyana Malek
 
Problems during labor and delivery 202
Problems during labor and delivery 202Problems during labor and delivery 202
Problems during labor and delivery 202shenell delfin
 
The Three Stages Of Labor And Delivery
The Three Stages Of Labor And DeliveryThe Three Stages Of Labor And Delivery
The Three Stages Of Labor And Deliverysandrute3
 
Final first stage of labour
Final first stage of labourFinal first stage of labour
Final first stage of labourBalkeej Sidhu
 
6.Normal Labor,Delivery And The Puerperium
6.Normal Labor,Delivery And The Puerperium6.Normal Labor,Delivery And The Puerperium
6.Normal Labor,Delivery And The PuerperiumDeep Deep
 
Obstetric analgesia
Obstetric analgesia  Obstetric analgesia
Obstetric analgesia Souvik Maitra
 
Psychological changes during puerperium1
Psychological changes during puerperium1Psychological changes during puerperium1
Psychological changes during puerperium1تائب لله
 
Mental health disorders in pregnancy
Mental health disorders in pregnancyMental health disorders in pregnancy
Mental health disorders in pregnancySami Shawer
 
Normal labor and delivery
Normal labor and deliveryNormal labor and delivery
Normal labor and deliveryAbie Dabs
 
Physiological changes in puerperium
Physiological changes in puerperiumPhysiological changes in puerperium
Physiological changes in puerperiumShrooti Shah
 
Summary of psychiatric disorders during pregnancy & lactation
Summary of psychiatric disorders during pregnancy & lactationSummary of psychiatric disorders during pregnancy & lactation
Summary of psychiatric disorders during pregnancy & lactationHosam Hassan
 
Nursing management during labor and birth two dunn
Nursing management during labor and birth two dunnNursing management during labor and birth two dunn
Nursing management during labor and birth two dunncbear1996
 

Viewers also liked (18)

Don't fear delivery pain
Don't fear delivery painDon't fear delivery pain
Don't fear delivery pain
 
Pregnancy as a psychological event
Pregnancy as a psychological event Pregnancy as a psychological event
Pregnancy as a psychological event
 
Psychological changes of pregnancy
Psychological changes of pregnancyPsychological changes of pregnancy
Psychological changes of pregnancy
 
Challenges in obstetrics and gynaecology psychological perspective
Challenges in obstetrics and gynaecology   psychological perspectiveChallenges in obstetrics and gynaecology   psychological perspective
Challenges in obstetrics and gynaecology psychological perspective
 
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTH
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTHNURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTH
NURSING CARE OF MOTHER AND BABY DURING LABOR AND BIRTH
 
Postpartum psychiatric disorder
Postpartum psychiatric disorderPostpartum psychiatric disorder
Postpartum psychiatric disorder
 
Problems during labor and delivery 202
Problems during labor and delivery 202Problems during labor and delivery 202
Problems during labor and delivery 202
 
The Three Stages Of Labor And Delivery
The Three Stages Of Labor And DeliveryThe Three Stages Of Labor And Delivery
The Three Stages Of Labor And Delivery
 
Care of the mother, child and family (NCM 101)
Care of the mother, child and family (NCM 101)Care of the mother, child and family (NCM 101)
Care of the mother, child and family (NCM 101)
 
Final first stage of labour
Final first stage of labourFinal first stage of labour
Final first stage of labour
 
6.Normal Labor,Delivery And The Puerperium
6.Normal Labor,Delivery And The Puerperium6.Normal Labor,Delivery And The Puerperium
6.Normal Labor,Delivery And The Puerperium
 
Obstetric analgesia
Obstetric analgesia  Obstetric analgesia
Obstetric analgesia
 
Psychological changes during puerperium1
Psychological changes during puerperium1Psychological changes during puerperium1
Psychological changes during puerperium1
 
Mental health disorders in pregnancy
Mental health disorders in pregnancyMental health disorders in pregnancy
Mental health disorders in pregnancy
 
Normal labor and delivery
Normal labor and deliveryNormal labor and delivery
Normal labor and delivery
 
Physiological changes in puerperium
Physiological changes in puerperiumPhysiological changes in puerperium
Physiological changes in puerperium
 
Summary of psychiatric disorders during pregnancy & lactation
Summary of psychiatric disorders during pregnancy & lactationSummary of psychiatric disorders during pregnancy & lactation
Summary of psychiatric disorders during pregnancy & lactation
 
Nursing management during labor and birth two dunn
Nursing management during labor and birth two dunnNursing management during labor and birth two dunn
Nursing management during labor and birth two dunn
 

Similar to Mania - a psychological perspective (talk 2)

The recognition of bipolar disorder in primary care
The recognition of bipolar disorder in primary careThe recognition of bipolar disorder in primary care
The recognition of bipolar disorder in primary careNick Stafford
 
Bipolar treatment skilled nursing
Bipolar treatment skilled nursingBipolar treatment skilled nursing
Bipolar treatment skilled nursingMichael Changaris
 
Bipolar basics for MRCPsych year 1
Bipolar basics for MRCPsych year 1Bipolar basics for MRCPsych year 1
Bipolar basics for MRCPsych year 1Nick Stafford
 
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Arletha Thomas
 
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Arletha Thomas
 
Mood Disorders Mental Health Nursing Chapter 16 Part Ii
Mood Disorders Mental Health Nursing Chapter 16   Part IiMood Disorders Mental Health Nursing Chapter 16   Part Ii
Mood Disorders Mental Health Nursing Chapter 16 Part Iilifeisgood727
 
Mood Disorder and Suicide
Mood Disorder and SuicideMood Disorder and Suicide
Mood Disorder and Suicidejumar ubalde
 
Seminar on approach to schizophrenia.pptx
Seminar on approach to schizophrenia.pptxSeminar on approach to schizophrenia.pptx
Seminar on approach to schizophrenia.pptxfiraolgebisa
 
Psicopatologia
PsicopatologiaPsicopatologia
Psicopatologiapsymen67
 
PostPartum PSYCHIATRIC DISORDERS-OT
PostPartum PSYCHIATRIC DISORDERS-OTPostPartum PSYCHIATRIC DISORDERS-OT
PostPartum PSYCHIATRIC DISORDERS-OTRaviteja Innamuri
 
Major depression
Major depressionMajor depression
Major depressionReynel Dan
 
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptxOVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptxValentinaEmeruwa
 
Viewpoints on Psychopathology
Viewpoints on PsychopathologyViewpoints on Psychopathology
Viewpoints on PsychopathologyBryn Robinson
 
bipolar affective disorder
bipolar affective disorderbipolar affective disorder
bipolar affective disorderPritesh Patel
 
Differential diagnosis
Differential diagnosis Differential diagnosis
Differential diagnosis Nasar Khan
 
Depression- Diagnosis, Causes, Treatments
Depression- Diagnosis, Causes, Treatments Depression- Diagnosis, Causes, Treatments
Depression- Diagnosis, Causes, Treatments Aaradhana Reddy
 
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body Health
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body HealthUnderstanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body Health
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body HealthMichael Changaris
 

Similar to Mania - a psychological perspective (talk 2) (20)

The recognition of bipolar disorder in primary care
The recognition of bipolar disorder in primary careThe recognition of bipolar disorder in primary care
The recognition of bipolar disorder in primary care
 
Bipolar treatment skilled nursing
Bipolar treatment skilled nursingBipolar treatment skilled nursing
Bipolar treatment skilled nursing
 
Bipolar-ppt
Bipolar-pptBipolar-ppt
Bipolar-ppt
 
Bipolar basics for MRCPsych year 1
Bipolar basics for MRCPsych year 1Bipolar basics for MRCPsych year 1
Bipolar basics for MRCPsych year 1
 
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
 
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
Mooddisordersmentalhealthnursingchapter16 Partii 091112080813 Phpapp02
 
Mood Disorders Mental Health Nursing Chapter 16 Part Ii
Mood Disorders Mental Health Nursing Chapter 16   Part IiMood Disorders Mental Health Nursing Chapter 16   Part Ii
Mood Disorders Mental Health Nursing Chapter 16 Part Ii
 
Mood Disorder and Suicide
Mood Disorder and SuicideMood Disorder and Suicide
Mood Disorder and Suicide
 
Seminar on approach to schizophrenia.pptx
Seminar on approach to schizophrenia.pptxSeminar on approach to schizophrenia.pptx
Seminar on approach to schizophrenia.pptx
 
Psicopatologia
PsicopatologiaPsicopatologia
Psicopatologia
 
PostPartum PSYCHIATRIC DISORDERS-OT
PostPartum PSYCHIATRIC DISORDERS-OTPostPartum PSYCHIATRIC DISORDERS-OT
PostPartum PSYCHIATRIC DISORDERS-OT
 
Major depression
Major depressionMajor depression
Major depression
 
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptxOVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
OVERVIEW OF SOMATOFORM DISORDERS AND ITS MANAGEMENT.pptx
 
BIPOLAR DISORDER
BIPOLAR DISORDERBIPOLAR DISORDER
BIPOLAR DISORDER
 
Viewpoints on Psychopathology
Viewpoints on PsychopathologyViewpoints on Psychopathology
Viewpoints on Psychopathology
 
bipolar affective disorder
bipolar affective disorderbipolar affective disorder
bipolar affective disorder
 
Mood disorders
Mood disordersMood disorders
Mood disorders
 
Differential diagnosis
Differential diagnosis Differential diagnosis
Differential diagnosis
 
Depression- Diagnosis, Causes, Treatments
Depression- Diagnosis, Causes, Treatments Depression- Diagnosis, Causes, Treatments
Depression- Diagnosis, Causes, Treatments
 
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body Health
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body HealthUnderstanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body Health
Understanding Bipolar Disorder: Biopsychosocial Approaches to Mind Body Health
 

More from Nick Stafford

Current and future research developments in mood disorders psychopharmacology
Current and future research developments in mood disorders psychopharmacologyCurrent and future research developments in mood disorders psychopharmacology
Current and future research developments in mood disorders psychopharmacologyNick Stafford
 
Personality Disorders and Depression - GP management update, BMJ Masterclass,...
Personality Disorders and Depression - GP management update, BMJ Masterclass,...Personality Disorders and Depression - GP management update, BMJ Masterclass,...
Personality Disorders and Depression - GP management update, BMJ Masterclass,...Nick Stafford
 
The effective management of bipolar between primary and secondary care
The effective management of bipolar between primary and secondary careThe effective management of bipolar between primary and secondary care
The effective management of bipolar between primary and secondary careNick Stafford
 
The complexities of diagnosing bipolar disorder in primary and secondary care
The complexities of diagnosing bipolar disorder in primary and secondary careThe complexities of diagnosing bipolar disorder in primary and secondary care
The complexities of diagnosing bipolar disorder in primary and secondary careNick Stafford
 
The neurobiology and pharmacotherapy of bipolar
The neurobiology and pharmacotherapy of bipolarThe neurobiology and pharmacotherapy of bipolar
The neurobiology and pharmacotherapy of bipolarNick Stafford
 
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...Nick Stafford
 
How to set up a mood disorders clinic
How to set up a mood disorders clinicHow to set up a mood disorders clinic
How to set up a mood disorders clinicNick Stafford
 
MRCPsych Year 1 depression lecture sept 2013
MRCPsych Year 1 depression lecture sept 2013MRCPsych Year 1 depression lecture sept 2013
MRCPsych Year 1 depression lecture sept 2013Nick Stafford
 
An integrated care pathway for the screening, assessment and diagnosis of bip...
An integrated care pathway for the screening, assessment and diagnosis of bip...An integrated care pathway for the screening, assessment and diagnosis of bip...
An integrated care pathway for the screening, assessment and diagnosis of bip...Nick Stafford
 
Relationships and mental illness
Relationships and mental illnessRelationships and mental illness
Relationships and mental illnessNick Stafford
 

More from Nick Stafford (10)

Current and future research developments in mood disorders psychopharmacology
Current and future research developments in mood disorders psychopharmacologyCurrent and future research developments in mood disorders psychopharmacology
Current and future research developments in mood disorders psychopharmacology
 
Personality Disorders and Depression - GP management update, BMJ Masterclass,...
Personality Disorders and Depression - GP management update, BMJ Masterclass,...Personality Disorders and Depression - GP management update, BMJ Masterclass,...
Personality Disorders and Depression - GP management update, BMJ Masterclass,...
 
The effective management of bipolar between primary and secondary care
The effective management of bipolar between primary and secondary careThe effective management of bipolar between primary and secondary care
The effective management of bipolar between primary and secondary care
 
The complexities of diagnosing bipolar disorder in primary and secondary care
The complexities of diagnosing bipolar disorder in primary and secondary careThe complexities of diagnosing bipolar disorder in primary and secondary care
The complexities of diagnosing bipolar disorder in primary and secondary care
 
The neurobiology and pharmacotherapy of bipolar
The neurobiology and pharmacotherapy of bipolarThe neurobiology and pharmacotherapy of bipolar
The neurobiology and pharmacotherapy of bipolar
 
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...
Integrated Care Pathway for Bipolar Disorder. Seminar to the Westgate GP Prac...
 
How to set up a mood disorders clinic
How to set up a mood disorders clinicHow to set up a mood disorders clinic
How to set up a mood disorders clinic
 
MRCPsych Year 1 depression lecture sept 2013
MRCPsych Year 1 depression lecture sept 2013MRCPsych Year 1 depression lecture sept 2013
MRCPsych Year 1 depression lecture sept 2013
 
An integrated care pathway for the screening, assessment and diagnosis of bip...
An integrated care pathway for the screening, assessment and diagnosis of bip...An integrated care pathway for the screening, assessment and diagnosis of bip...
An integrated care pathway for the screening, assessment and diagnosis of bip...
 
Relationships and mental illness
Relationships and mental illnessRelationships and mental illness
Relationships and mental illness
 

Recently uploaded

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...Sujoy Dasgupta
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdfHongBiThi1
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024EwoutSteyerberg1
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 

Recently uploaded (20)

SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio..."Radical excision of DIE in subferile women with deep infiltrating endometrio...
"Radical excision of DIE in subferile women with deep infiltrating endometrio...
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdfSGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA    .pdf
SGK NGẠT NƯỚC ĐHYHN RẤT LÀ HAY NHA .pdf
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...Rheumatoid arthritis Part 1, case based approach with application of the late...
Rheumatoid arthritis Part 1, case based approach with application of the late...
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024Trustworthiness of AI based predictions Aachen 2024
Trustworthiness of AI based predictions Aachen 2024
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Biologic therapy ice breaking in rheumatology, Case based approach with appli...
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 

Mania - a psychological perspective (talk 2)

  • 1. Mania A psychological perspective Dr. Nick Stafford
  • 3. THE BIOLOGY OF THE PSYCHOLOGY
  • 4. Some putative biological mechanisms Cortisol/HPA/HPT Sleep & circadian dysregulation Neural degeneration Oxidative stress Inflammatory processes Apoptosis Prefrontal dysfunction Amygdala / hippocampal dysfunction Affect regulation activations
  • 15. Psychosocial risk factors Illness Life events Current environment Early environment
  • 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
  • 34. DYSREGULATION OF THE CIRCADIAN RHYTHMS
  • 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
  • 45. How might circadian disruption lead to bipolar symptoms
  • 47. Disturbed psychological functioning in bipolar disorder
  • 48. Variability in the impact of circadian disruption
  • 49. Kindling theory and the impact of life events
  • 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
  • 54. There is Clinical Evidence for … CBT FFT IPSRT PE
  • 55. EARLY WARNING SIGNS & COPING STRATEGIES
  • 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
  • 67. Psychoeducation Evidence [Colom et al., 2009, Brit J Psych]
  • 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
  • 70. CT
  • 71. CT
  • 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
  • 75. IPSRT
  • 76. IPSRT
  • 78. FFT
  • 81. Where is your mind now?
  • 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
  • 86. DBT
  • 87. DBT’s five core modules / skills • Mindfulness • Distress tolerance • Emotion regulation • Interpersonal effectiveness • Self management
  • 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
  • 90. Evidence for DBT in Bipolar Goldstein et al 2007
  • 92. Summary of psychosocial interventions
  • 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?
  • 94. Treatment • Historical management to prevent bipolar relapse • Psychological treatment
  • 95. Biopsychosocial approaches • Psychoeducation • IPSRT • DBT • CBT
  • 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)
  • 101. OVERSENSITIVITY OF THE BEHAVIOURAL ACTIVATION SYSTEM
  • 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
  • 121. Acknowledgments • Thomas Meyer. Newcastle University.

Editor's Notes

  1. http://ajp.psychiatryonline.org/article.aspx?articleID=99957#Bipolar%20Disorder%20and%20Sleep%20Disturbance%20Often%20Coexist