Coping with Bipolar Disorder: Eight Practical Strategies for Enhancing Wellness

Transcription

1 Coping with Bipolar Disorder: Eight Practical Strategies for Enhancing Wellness David J. Miklowitz, Ph.D. Professor of Psychiatry Division of Child and Adolescent Psychiatry UCLA Semel Institute and Department of Psychiatry, Oxford University Child and Adolescent Mood Disorders Clinic (310)

2 Upon Hearing the Diagnosis of Bipolar Disorder The endless questioning finally ended. My psychiatrist looked at me, there was no uncertainty in his voice. Manic-depressive illness. I admired his bluntness. I wished him locusts on his lands and a pox upon his house. Silent, unbelievable rage. I smiled pleasantly. He smiled back. The war had just begun. --Kay Redfield Jamison An Unquiet Mind (1993)

3 Thirty Years of research on bipolar disorder has taught me that.

4 managing bipolar disorder is more than just taking medicines.

5 The 8 Self-Care Principles 1. Monitor your moods daily/know your early warning signs 2. Recognize and manage stress triggers 3. Stabilize your sleep/wake rhythms 4. Know your position on medications 5. Develop a mania prevention plan 6. Work on communication with your family/partner 7. Obtain reasonable accommodations at work or school 8. Get regular therapy or join a support group From: Miklowitz DJ (2011). The Bipolar Disorder Survival Guide, 2 nd Ed

6 Principle #1 Monitor your moods Know your early warning signs

7 Handout # 2 Increased energy and activity Increased sexual thoughts Decreased need for sleep Symptoms of Mania IRRITABILITY! Elated mood Being overconfident or unrealistic Talking fast Loss of self-control Easily distracted, Racing Thoughts, Lots of ideas

8 Handout # 2b Low self-esteem Low mood or sadness Symptoms of Depression Tearfulness Trouble concentrating Some people also: feel really tired or low in energy wish they weren t alive feel worthless or guilty talk or move slowly lack of thoughts Sleeping too much or too little Increase or Decrease in Appetite Crave Sweets or Carbohydrates Loss of interest in activities/boredom

9 Daily monitoring of mood symptoms Keep a daily mood chart This is one of the things you can do in addition to taking medications to gain more control of the illness How is your mood affected by stress, alcohol, medications?

10 HOW I FEEL Week of Mar 3 Super-Hyper Energized Balanced Down Angry Monday Tuesday Wednesday Thursday Friday Saturday Sunday X X X X X X X I woke up at: I went to bed at: :30 10: Examples of: Super-Hyper Down Angry Feel good about myself Suicidal Pissed off Talk faster Don t want to go to school Hate everyone Like being high Short-tempered Irritable Lots of ideas Stop eating or eat more Snap easily Need less sleep Want to be alone Want to live in a bubble

11 Principle #2 Recognize your stress triggers

12 Examples of Stress Loss of a loved one Conflict with a spouse or parent High levels of criticism from others Parenting problems Constantly changing work hours Increased job or school demands Financial problems Legal issues

13 Factors Affecting Mood Swings Genes Stress Possible Outcomes Good Okay Poor

14 Managing Stress: The 3-Minute Breathing Space Sit in comfortable chair with your back upright Close eyes or stare at an object. For 60 seconds, be aware of noises in the room acknowledge each sensation, thought, or feeling, whether pleasant or unpleasant For 60 seconds, focus on in-breath and out-breath; if attention shifts, gently escort yourself back to your breathing For 60 seconds, shift your attention to your entire body notice posture and sensations in different parts of the body as you breathe in and out Slowly open your eyes and come back in contact with the room Source: Segal, Williams, & Teasdale, 2001; Mindfulness-based cognitive therapy for depression. NY: Guilford

15 Principle #3 Stabilize your sleep/wake rhythms

16 Good Sleep Hygiene Establish a regular bedtime and wake time Vary a maximum of 1 hour/day Avoid sleep bingeing on weekends Avoid caffeine and other stimulants at night Avoid alcohol, illicit drugs, or activating over-the-counter medications Exercise early in the day, not right before bed Avoid working in bedroom before bed When traveling, normalize sleep/wake rhythms as soon as possible

17 Principle #4 Know your position on medications

18 FDA-Approved Bipolar Disorder Treatments in Adults Agents Mani Agents Manic Mixed Maintenance Depression c d ce ATYPICALS ATYPICALS Aripiprazole Aripiprazole (Abilify (Abilify ) ) Olanzapine Olanzapine (Zyprexa (Zyprexa ) ) Quetiapine Quetiapine (SEROQUEL (SEROQUEL ) ) Risperidone Risperidone (Risperdal (Risperdal ) ) Ziprasidone Ziprasidone (Geodon (Geodon ) ) OTHER OTHER Carbamazepine Carbamazepine ER (Equetro ER (Equetro ) TM ) Divalproex Divalproex DR (Depakote DR (Depakote ) ) + + Divalproex Divalproex ER (Depakote ER (Depakote ER) ER) This chart does not imply comparable Lamotrigine (Lamictal efficacy or safety profiles. Lamotrigine (Lamictal ) ) + registered trademarks of Lithium (Lithobid their respective, Eskalith owners. Lithium (Lithobid, Eskalith ) ) Olanzapine/fluoxetine Olanzapine/fluoxetine (Symbyax + All brand names and product names used in this slide are trade names, service marks, trademarks, or

19 Adherence to a Mood Stabilizer Regimen People with bipolar disorder are more likely to commit to a mood stabilizer regimen if They receive information from mental health professionals about the disorder and how the medications will help They are approached with compassion and with acknowledgement that taking medications doesn t change one s identity It is their own decision and not one foisted on them by others Dosages can be adjusted or other medications substituted to control side effects

20 Troubleshooting Medication Adherence Discuss side effects with doctor Develop strategies for pill storage and use Role of medications in your family/marriage Do you feel you re taking meds for yourself or others? Pressures from family members to discontinue medications? What is the symbolic significance of taking medications (loss of creativity? Giving up emotions)? Grieving over the lost healthy self 1 Miklowitz DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, Frank E, et al. Biol Psychiatry 48(6): , 2000.

21 Who Should be in Charge of My Child s/teen s Medications? If kid is to take responsibility, he or she must buy into the diagnosis and treatment plan The kid must be cognitively able to handle the dosing requirements Issue of boundaries - is kid more or less likely to take meds. if parents take a directive role? Older kids are more likely to be able to take responsibility than younger kids Make sure that medications do not become the battleground in which autonomy battles are fought

22 Principle #5 Develop a mania prevention plan

23 The Mania Prevention List prodromal signs Contract List circumstances in which, historically, these have been most likely to occur What can you do? What can your spouse/parents/siblings do? The psychiatrist? Therapist? Have all emergency contact info in one place 23

24 Elements of an Early Response Plan for Escalating Mania Contact physician for an emergency appointment or have a small supply of antipsychotic medication available Be aware of hospital resources and admission procedures Keep environment structured and low key Stay away from alcohol and drugs Try to get enough sleep!

25 Elements of an Early Response Plan for Escalating Mania (Continued) Bring someone you trust with you when you go out at night Get help managing money, give up car keys Avoid making major life decisions (use 2-person rule, 48-hour rule: if it s a good idea now, it ll be a good idea then ) 1 1 Newman CF, et al. Bipolar Disorder: A Cognitive Therapy Approach. Washington, DC: American Psychological Association, 2001.

26 Principle #6 Work on communication with your partner/family

27 A mother s perspective. That s me on that string my son is like a big baby puppeteer, keeping us all on a string with his vicious mood swings. Worst of all he seems delighted that he can do it.

28 How Can The Family Help? Help you get treatment and support services (e.g., disability) Support your use of medication Maintain tolerant and calm home atmosphere Have fair expectations of you and other family members Keep regular family routines (e.g., mealtimes) Know their own limits

29 The Four Basic Communication Skills Expressing Positive Feelings Active Listening Making Positive Requests for Change Expressing Negative Feelings about Specific Behaviors

30 Active Listening Look at the Speaker Attend to What is Said Nod Head, Say Uh-Huh Ask Clarifying Questions Check Out What You Heard

31 Making a Positive Request Look at the Person Say Exactly What You Would Like Him or Her to Do Tell Him or Her How You Would Feel When S/He Did That In Making Positive Requests, Use Phrases Like: I would like you to. I would really appreciate it if you would. It s very important to me that you help me with.

32 Principle #7 Obtain reasonable accommodations at work or school

33 Reasonable accommodations in the work setting Modified work hours (eg avoiding early mornings, keeping regular hours) Support for stress management (eg short breaks, working in well-lit rooms) Absences from work for medical care or stress reduction Open communication with your employer regarding job performance and working conditions

34 For Parents of Bipolar Kids: Reasonable Accommodations in the School Setting Help teachers distinguish bipolar disorder from other psychiatric disorders Develop plan to manage behavioral problems Allow later starts to the day Allow more frequent breaks, time outs, school counseling visits Have escape hatches during periods of escalation (e.g., in-school counseling) Excused absences for medical appointments Individualized educational plans Reducing overstimulation in classroom Parent as advocate

35 Disclosure and Stigma: How Much Should We Tell Others About What s Going On? What s the purpose of the disclosure? What do you expect to achieve? Who should be told boss, coworker, teacher? Friends? What do you want them to do with the information? Is purpose of disclosure primarily to alleviate your distress? If so, consider support group as setting for disclosure

36 Principle #8 Get regular therapy or join a support group Should have a psychoeducational focus Weekly or biweekly is optimal

37 Family-Focused Treatment (FFT) of Bipolar Disorder 21 outpatient sessions over 9 months Assessment of patient and family Engagement phase Psychoeducation about bipolar disorder (symptoms, early recognition, etiology, treatment, selfmanagement) Communication enhancement training (behavioral rehearsal of effective speaking and listening strategies) Problem-solving skills training Miklowitz DJ & Goldstein MJ. Bipolar Disorder: A Family-Focused Treatment Approach. NY: Guilford Press, 1997.

38 The STEP-BD Multisite Program (15 sites, N=293) (Miklowitz et al., 2007; Arch Gen Psychiatry) 2(3) = 8.02, p = Hazard Ratios (vs CC) CBT: 1.34, p =.12 FFT: 1.87, p =.013 IPSRT: 1.48, p =.048

39 I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy ineffably, psychotherapy heals. It makes some sense of the confusion, reigns in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all It is where I have believed or have learned to believe that I might someday be able to contend with all of this. -Kay Jamison, Ph.D., An Unquiet Mind, 1995

40 Summary: 8 Self-Care Principles 1. Monitor your moods daily/know your early warning signs 2. Learn to recognize and manage stress triggers 3. Stabilize your sleep/wake rhythms 4. Know your position on medications 5. Develop a mania prevention plan 6. Work on communication with your family/partner 7. Obtain reasonable accommodations at work or school 8. Get regular therapy or join a support group From: Miklowitz DJ (2010). The Bipolar Disorder Survival Guide, 2 nd Ed

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42 Child and Adolescent Mood Disorders Program (CHAMP) (310)