Modalities of Treatment for Bipolar I Disorder. Angela Shock. Mercer University

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1 Running Head: MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 1 Modalities of Treatment for Bipolar I Disorder Angela Shock Mercer University

2 MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 2 Bipolar disorder is typically considered to be a heritable, biologically based disorder, with effective treatment most often coming in the form of medication (pharmacotherapy). The gold standard of pharmacological treatment, and the recommended initial intervention tool for stabilizing mood, is lithium (Frank et al., 2000). It is sometimes used alone, but is most generally combined with an anticonvulsant and other possible adjunctive agents, such as calcium channel blockers, atypical antipsychotics and antidepressants (Rivas-Vazquez et al., 2002). Based on extensive testing, drug therapy has worked best for controlling the cycling from manic to depressive episodes during the course of the disorder. By nature, it is a recurrent illness, even when patients are treated consistently with drugs, relapse occurs at an alarming rate. Over a five year span, 73% of patients will experience relapse. Those with bipolar disorder have an overall lifetime risk of 19% for suicide, which is 30 times greater than that of the normal population and is the highest suicide rate for any mental disorder (Miklowitz and Alloy, 1999). Although drug therapy has remained the unremitting primary treatment for bipolar disorder, psychotherapy methods have become increasingly recognized for their effectiveness in assuaging symptoms of the disorder (Rivas-Vazquez et al., 2002). The primary aim in psychotherapy of bipolar clients is to increase their compliance with their medication regimen; it is alarmingly common for bipolar individuals to either refuse drug treatment entirely or to take medication sporadically. Counseling interventions also aim to reduce the risk factors associated with mood instability in their clients. These factors include family stress, marital conflicts, and difficulties at work or with unemployment. Additionally, counselors will want to specifically work with their clients to reduce magnified levels of expressed emotion, such as negative criticism, hostility or emotional over-involvement (Rivas-Vazquez et al., 2002).

3 MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 3 The goals of psychotherapy for individuals with bipolar disorder generally revolve around enhancing occupational and social functioning, strengthening familial and spousal support systems, and identifying psychosocial stressors that may trigger mood episodes (Rivas- Vazquez et al., 2002). Research conducted by Miklowitz and Alloy (1999) showed that higher social support is associated with more rapid recovery from a bipolar episode. Conversely, they found that stressful life events have proven to result in longer recovery intervals (Miklowitz and Alloy, 1999). Over the last 20 years, various modalities of psychotherapy have been developed in response to the challenges of bipolar disorder, most generally including family and marital treatment, group approaches, and individual approaches. Specific individual approaches which have shown promise include cognitive-behavioral treatment (CBT) and Interpersonal and Social Rhythm Therapy (IPSRT) (Rivas-Vazquez et al., 2002). There is evidence that expressed emotions, including negative criticism, hostility and emotional over-involvement are powerful triggers for relapse in bipolar disorder. Family and marital therapy have received attention, as these therapies make an effort to contain such emotion surrounding the bipolar individual. Specifically, family focused treatment (FFT) has emerged in order to improve family functioning by providing training in communication and problem-solving. Family members are also educated about all aspects of bipolar disorder. A study conducted by Rivas-Vazquez et al. (2002) has suggested that the psychoeducation provided specifically to spouses of bipolar clients resulted in a marked improvement in the clients level of social adjustment and global functioning (p. 220). This treatment is an adaptation of a previously successful intervention for schizophrenics (Rivas-Vazquez et al., 2002).

4 MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 4 Various group therapy approaches have been devised and tested for clients with bipolar disorder with highly mixed results. One promising therapy to emerge is the Life Goals Program, a group therapy program that relies on structured meetings and manual-based training for its members (Rivas-Vazquez et al., 2002). It consists of a first phase of psycho-education sessions followed by a second phase of behavioral strategies aimed at attaining an occupational, social or leisure goal that may have been previously disrupted by bipolar disorder. Each group member eventually focuses on a personal goal, whether it be to re-enter the workforce or to simply learn to play a team sport. The Life Goals Program can be acquired by counselors for use with their bipolar clients (Bauer et al., 1998). An individual approach to counseling bipolar disordered clients, which has met with great success, is Interpersonal and Social Rhythm Therapy (IPSRT). This therapy is originally derived from Interpersonal Psychotherapy for Depression (IPT), a modality that rests on the principle that for biologically vulnerable individuals various stressful interpersonal events will spur the onset of depression (Frank et al, 2000). It is a here and now treatment that recognizes that depressive symptoms can lower an individual s capacity to negotiate conflict and to find constructive solutions to interpersonal problems (Frank et al., 2000, p. 596). This treatment focuses on four problem areas: grief, role disputes, role transitions, and interpersonal deficits (Frank et al., 2000). Later on, IPT was augmented with behavioral interventions designed to stabilize daily routines (Frank et al., 2000). This shaping of the therapy is based on the postulation that certain life events may trigger bipolar episodes by disrupting stable activities or time cues, such as regularly scheduled times for eating, sleep, exercise and work (Rivas-Vazquez et al., 2002). This

5 MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 5 is significant because bipolar clients with higher levels of stress are 4.5 times more likely to have a mood disorder relapse than those with low levels of life stress. Events that can cause disruptions in daily routines or sleep-wake cycles (social rhythms), and hence trigger unnecessary stress, include transmeridian air travel and changes in work schedules (Miklowitz and Alloy, 1999). By borrowing from traditional cognitive-behavioral techniques, therapists were able to use self-monitoring, realistic goal-setting, and graded assignments to enable clients to follow more consistent lifestyle patterns (Frank et al., 2000). Interpersonal and Social Rhythm Therapy (IRSRT) officially surfaced some time later as a manual-based therapy that focused on 1) the connection between mood and life events, 2) the importance of maintaining a regular daily routine, 3) the identification and management of potential disruptors of daily rhythm (including interpersonal triggers), 4) reinforcement for mourning the lost healthy self, and 5) the identification and management of affective symptoms (Frank et al., 2000). Studies conducted using IRSRT indicate that, in conjunction with pharmacotherapy, it can aid in the effective treatment bipolar disorder by increasing stability in routines and daily rhythms (Rivas-Vazquez et al., 2002).

6 MODALITIES OF TREATMENT FOR BIPOLAR I DISORDER 6 References Frank, E., Swartz, H.A., & Kupfer, D.J. (2000). Interpersonal and social rhythm therapy: Managing the chaos of bipolar disorder. Society of Biological Psychiatry, (48)1, Miklowitz, D.J. & Alloy, L.B. (1999). Psychosocial factors in the course and treatment of bipolar disorder: Introduction to the special section. Journal of Abnormal Psychology, (108)4, Rivas-Vazquez, R.A., Johnson, S.L., Rey, G.J., & Blais, M.A. (2002). Current treatments for bipolar disorder: A review and update for psychologists. Professional Psychology: Research and Practice, (33)2,

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