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Introduction
Bipolar disorder is the experience of repeatedly different mood episodes that significantly disturbed individuals’ activity level. On some occasions, the individuals will experience an elevation of mood, energy and activity level; while on another time, the individuals will experience a lowering of mood, energy and activity (found ( found in all individuals i ndividuals who suffered from Bipolar Disorder except those who experience elevation only). Bipolar disorder is a pervasive and chronic disorder which at least moderately impaired individuals’ daily
functioning. According to Diagnostic and Statistical Manual of Mental M ental Disorder (DSM), there are four main types of Bipolar Disorder, which are: 1) Bipolar I Disorder 2) Bipolar II Disorder 3) Cyclothymic Disorder 4) Substance/Medication-Induced Substance/Medication-Induced Bipolar and Related Disorder (DSM-5) 5) Bipolar and Related Disorder due to Another Medical Condition (DSM-5) 6) Bipolar Disorder Not Otherwise Specified (DSM-IV-TR)/Other Specified or Unspecified Bipolar and Related Disorders (DSM-5) A. PROBLEM IDENTIFICATION IDENTIFICATION I. Types of Mood Episodes Episode 1) Diagnostic criteria of M anic Episode in DSM-IV-TR are as below (APA, 2000):
Criteria A: Manic episode is a distinct period during in which individual experience abnormal abnormal and persistent elevated, expansive, expansive, or irritable mood. This period must last for at least 1 week (or less if hospitalization is needed). Criteria B: The mood disturbance must including at least three following symptoms significantly: (a) inflated self-esteem or grandiosity (b) decrease need for sleep (c) pressure of speech (d) flights of ideas (e) distractibility (f) increase involvement in goal-directed activity or psychomotor agitation (g) excessive involvement in activities that are potentially resulting in painful consequences. Criteria C: The symptoms do not meet the criteria of Mixed Episode. Criteria D: The mood disturbances is severe enough to cause marked impairment in social or occupational occupational functioning, necessity to be hospitalized, or presence of psychotic features. Criteria E: The symptoms are not due to direct physiological effect of substance or general medical condition. 2) Diagnostic criteria of M ajor Depress in DSM-IV-TR are as below (APA, Depressive Epi sode 2000):
Criteria A: The essential ffeature eature of Major Depressive Episode is either the presence of depressed mood or loss of interest or pleasure for at least 2 weeks. While in children and adolescents, adolescents, the mood may be irritable rather than sad. During this period, the individual must also experience at least four additional symptoms such as the following: (a) changes in appetite and weight not due to dieting
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(b) insomnia or hypersomnia h ypersomnia almost every day (c) psychomotor agitation or retardation that is observable (d) fatigue (e) feeling worthless or guilty (f) difficulty thinking, concentrating and making decision (g) recurrent thoughts of death, suicidal ideations, i deations, plans or attempts. Criteria B: The symptoms do not meet criteria for a Mixed Episode Criteria C: These symptoms must have either caused significant impairment in social, occupational occupational and other areas of functioning for individual with moderate or severe symptoms, or markedly the needs of increased effort in functioning for individual with milder s ymptoms. Criteria D: The symptoms s ymptoms are not caused by direct substance or general medical condition. Criteria E: The symptoms s ymptoms are not better accounted for by Bereavement Bereavement 3) Diagnostic criteria of M i xed Epi sodes in DSM-IV-TR are as below (APA, 2000): odes
Criteria A: Mixed Episode is a combined presence of symptoms in both Manic Episode and Major Depressive Episode. The duration of symptoms occurrence should be at least one week. Individual experience alternating moods and other symptoms in both episodes. Criteria B: The mood disturbance is severe enough to cause obvious impairment in occupational, occupational, social and other areas of functioning, or hospitalization is compulsory to avoid suicide and harm to others, or with psychotic features. Criteria C: Presence of symptoms are not physiologically caused by substance and general medical condition. (***Mixed Episode in DSM-IV-TR has been replaced with mixed features in DSM-5.) ypomani c Episode Episodes 4) Diagnostic criteria of H ypomani in DSM-IV-TR are as below (APA, 2000):
Criteria A: Hypomanic H ypomanic Episode is a distinct period in which individual continuously experienced elevated, elevated, expansive, or irritable mood that last throughout at least l east 4 consecutive days. These symptoms are obviously different from the usual non-depressed mood. Criteria B: During this period, individual experiences at least 3 symptoms (4 if experience irritable mood only) similar to Manic Episode. Criteria C: There is significant change in functioning which is not the usual characteristic of that individual when not ssymptomatic. ymptomatic. Its changes and mood disturbance and observable by others. *Criteria D: Manic episode is not sufficiently severe to cause marked impairment in social, occupational occupational and other areas of functioning, hospitalization, and there is no psychotic features. Criteria E: The symptoms s ymptoms are not physiologically caused by substance or general medical condition Note:*Main difference from manic episode episode II. Types of Bipolar Disorders 1) Bipolar I Disorde Disorderr
Bipolar I Disorder involves occurrence of at least one Manic Episodes or Mixed Episodes, and at least one Major Depressive Episode (except for single manic episode type) (APA, 2000). There are six types of Bipolar Disorder I in DSM-IV-TR, DSM- IV-TR, which are: (a) Single Manic Episode (b) Most Recent Episode Hypomanic (c) Most Recent Episode Manic (d) Most Recent Episode Mixed
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(e) Most Recent Episode Depressed (f) Most Recent Episode Unspecified (***Has been replaced by other specifier stated in ) 2) Bipolar I I Di sorder order
(a) It involves occurrence of at least one Hypomanic H ypomanic Episodes and at least one Depressive Episode within an individual. The diagnostic criteria is similar to Bipolar Disorder I except that the individual has no history of experiencing Manic or Mixed Episode in first 2 years of disturbances (APA, 2000). (b) Bipolar II Disorder has often been regarding as less severe and disabling psychopathology compared to Bipolar I Disorder due to the less severity s everity of hypomanic episodes. However, there are several issues that causes individuals with Bipolar II Disorder to have higher disability as: (i) Individual with Bipolar II disorder are difficult to be diagnosed due to insufficient number of assessment tools that are sensitive towards detecting Bipolar II disorder (Miller et al., 2009). (ii) They are less readily accept that they have Bipolar Disorder. This is because they recognized the depressive episodes as illness but not considering hypomanic episodes as part of their illness. This is because it is difficult to differentiate hypomanic magnification of emotions from ordinary emotional reactions (Orum, 2008), and they enjoy the sense of mastery and benefits of being fast-pacing and somewhat efficient during hypomanic episodes (Parker 2008). (iii) They attempted suicide more frequent, more lethal and more likely to complete suicide compared to individuals with Bipolar I disorder (Rihmer & Pestality, 1999). This can be explained by large portion of them live unwell most of their lifetime, mostly suffering from depressive symptoms (Benazzi, 2001). 3) Cyclothymi Cyclothymi c Di sorder
Its essential feature is chronic, fluctuating mood disturbances involving numerous periods of hypomanic symptoms and depressive symptoms symptoms (APA, 2000). According to DSM-IV-TR, the diagnostic criteria for Cyclothymic Disorder is as following: Criteria A: The presence pr esence of hypomanic symptoms and depressive symptoms do not meet criteria for Manic Episode and Major Depressive Episode *(insufficient number, severity, pervasiveness pervasiveness or duration). These These symptoms must must present for at least least 2 years for adult. Criteria B: The individual has not been free of symptoms mentioned in Criteria A for more than 2 months at a time during the 2-year 2- year period.* Criteria C: The symptoms are not better accounted for disorder related to Schizophrenia, and not physiologically caused by substances and general medical condition. Criteria D: The symptoms cause clinically marked impairment and distress in individuals’ social, occupational and other areas of functioning. Note: *= main difference difference from Bipolar I and and II Disorder 4) Bi polar Di sorder N ot Other Other wise Specif pecif ied
While for disorders with bipolar features that do not meet criteria for any specific Bipolar Disorder, it will be categorized under Bipolar Disorder Not Otherwise Specified in DSM-IVTR (or Other Specified or Unspecified Bipolar and Related Disorders in DSM-5) (APA, 2000, 2012). Examples of the features includes:
BIPOLAR DISORDER (a) Very rapid interchange i nterchange (over days) between manic symptoms and depressive symptoms. These symptoms meet threshold threshold criteria, but not minimal duration criteria for Manic, Hypomanic or Major Depressive Episodes. (b) Recurrent Hypomanic Episodes without presence of depressive symptoms after or during the hypomanic episodes. (c) A Manic or Mixed Episodes overlaid Delusional Disorder, residual Schizophrenia, or Psychotic Disorder Not Otherwise Specified. (d) Infrequent presence of hypomanic episodes along with chronic depressive symptoms that are difficult to be qualified for diagnosis of Cyclothymic Disorder. (e) Situation in which Bipolar Disorder is present based on clinici an’s clinical judgment, however unable to determine whether it is primary, and whether it is due to general medical condition or induced by substance. To better illustrate the differences, please refer to diagram below, which is adapted from International Medical Health Research Organization (IMHRO; 2013).
5) Spe Specif cif ier f or B ipol ar an d Related Related Di sorders
According to DSM-5, the specifiers are as following: Specifier Description With anxious distress (a) Presence of at least 2 symptoms in current or most recent episodes of mania, hypomania & depression: (i) Feeling tense or keyed up (ii) Feeling restless that is unusual (iii) Feeling worry and that cause difficulty concentrating (iv) Afraid that something awful may happen (v) Feeling might lose control of oneself (b) Severity: Mild= 2 symptoms Moderate= 3 symptoms Moderate-severe= Moderate-severe= 4-5 symptoms Severe= 4-5 symptoms with motor agitation With mixed feature (a) In those who are in current or most recent episodes of hypomanic/manic, hypomanic/manic, it is characterized as presence of full criteria of manic/hypomanic episode, HOWEVER with at least 3 symptoms of depressive episodes. In who are in current or most recent episodes of
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(c) For those who meet both full criteria of mania and depression at the same time, the diagnosis should be manic episodes, with mixed features. (d) Mixed symptoms must not be caused by physiological effect of substance. With rapid cycling (both Presence of at least 4 episodes of manic, hypomanic and Bipolar I & II disorder) major depressive episode which meet full criteria in the past 12 months. The episodes must be separated by a period of partial or full remissions of at least 2 months OR switch to the episode that has opposite polarity With melancholic features (a) At least having one of the following during severe period of current episode: (i) anhedonia (ii) lack of reactivity to usually pleasurable stimuli (b) At least 3 of the following (i) Distinct quality of depressed mood characterized by profound despondency, despair and/or moroseness or empty mood. (ii) Depression that is normally worse in the morning (iii) Wake up at least 2 hours earlier before usual awakening. (iv) Significant psychomotor agitation or retardation (v) Marked aneroxia or weight loss. (vi) Excessive or inappropriate guilt. With atypical features, Please refer to DSM-5 page 151-154 or related websites with psychotic features, with catatonia, with peripartum onset, with seasonal pattern. Remission Specifier (a) In partial remission- symptoms present but not meeting full criteria in current episodes OR period lasting less than 2 months without symptoms (b) In full remission- No significant signs or symptoms for past 2 months. Severity Specifier (a) Mild- number of symptoms just exceed a few that is required to meet diagnostic criteria, symptoms is distressing but manageable, result in minor impairment in social or occupational functioning. (b) Moderate- number and intensity of symptoms, and/or functional impairment are between “mild” and “severe”.
(c) Severe- number of symptoms is significantly in excess to make diagnosis, intensity is unmanageable and seriously distressing, and interfere with social and occupational functioning.
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6) Bipolar Disorders have concurrent features with other psychopathology, which often cause misdiagnosis due to features similarity. These psychopathology are: Psychopathology Types of Bipolar Features that differentiate both Disorder that share similar features Mood Disorder Due to General Medical Condition Substance Induced Mood Disorder Psychotic Disorder
Borderline Personality Disorder
Bipolar I, II Disorder, Cyclothymic Disorder
Presence as direct physiological consequences of a specific general medical condition (for eg. Hypothyroidism) Bipolar I, II Disorder, Presence as direct physiological Cyclothymic Disorder consequences of intoxification with or withdrawal from substance use, medication (antidepressant treatment) Bipolar I, II Disorder Sufficiency of number, duration, and pervasiveness of manic and depressive symptoms are less and presence of psychotic symptoms in psychotic disorders (can refer to symptoms, previous course, and family history). Cyclothymic Disorder Presence of mood symptoms in Borderline Personality Disorder are more pervasive and without period of free from symptoms even less than 2 months (however comorbidity can occur).
7) Bipolar Disorder can be present with other features and coexisting with other disorders: (a) Suicide attempt and ideation - mostly during depressive episodes and more common in clients with Bipolar II Disorder (Parker, 2008) (b) Violent behavior (for eg. child and domestic abuse) (c) Psychotic features (d) School truancy, school failure, occupational failure, divorce, or episodic antisocial behavior. (e) Alcohol and other Substance Use Disorders (f) Anorexia Nervosa, Bulimia Nervosa, Sleep Disorder, Panic Disorder, and Social Phobia. (g) Attention-Deficit/ Hyperactivity Disorder, Borderline Personality Disorder (h) Risk-taking behavior in individual with Bipolar Disorder 8) For Bipolar Disorder, there are differences of gender in manifestation of symptoms. These including: (a) Male are more likely to experience Manic Episode as their first episode, while female are more likely to experience Major Depressive Episode as their first episode. (b) Male experience equal or higher number of Manic Episodes, while female higher number of Major Depressive Disorder. (c) Rapid cycling are more common in female than male. 9) Further information on specific features of Bipolar Disorder (a) Risk-taking behavior in individual with Bipolar Disorder (i) Individuals with Bipolar Disorder are always characterized as being impulsive, always
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on-the-go, always engaged in goal-directed activities without proper planning and consideration of consequences and etc, especially when they are manic (Johnson et al., 2012). (ii) In fact, there are two subcriteria in DSM under criterion A in manic episode that describe these behavior (American Psychiatric Association, 2000). (iii) Interesting result from past research showed that individuals with Bipolar Disorder are more likely to report themselves as being impulsive compare to healthy individuals (perhaps the memory of being impulsive is readily available and the selfreport measure is more sensitive in detecting the changes) (Holmes et al, 2009; Lambardo et al., 2012). (iv) However, result from past research regarding the risk-taking behavior were inconsistent with criteria in DSM and generally known in individuals with Bipolar Disorder, as Holmes et al. (2009) found that only individuals with Bipolar Disorder and alcohol dependence issues more prone to engage in risk-taking behavior according to behavior measure, but not generally all individuals with Bipolar Disorder. Reddy et al. (2014) found that individuals with Bipolar Disorder were not more prone to risk-taking behavior compared to healthy individuals. (v) Follow by their study, Reddy et al. (2014) found that the possible explanation is the whether the individuals with Bipolar Disorder are taking antipsychotic medication. It was found that in their research that those who took antipsychotic medication were less likely to engage in risk-taking behavior compared to those who did not take. This still require further investigation in other research. (b) Rapid-cycling (i) 3 types of rapid cycling - rapid (greater than or equal to four episodes per year) - ultra-rapid (greater than or equal to four episodes within a month) - ultradian (cycling within a day; greater than or equal to 4 days within a week) (ii) Risk factors: younger age of onset, childhood physical and sexual abuse, non-adherence to medication for existing clients, taking antidepressant (controversial) (Altshuler et al., Calabrese et al, 2005; 1995; Fristalen et al., 2005; Leverich et al, 2002 as cited in Goldberg & Berk, 2010). (iii) Outcome: Poorer prognosis compared to typical cycling clients (Goldberg & Berk, 2010). B. ASSESSMENTS I. Diagnostic Procedure of Bipolar Disorders
According to Martin (2006), below are the procedure to assess and diagnose Bipolar Disorder: 1) Initial Assessment (a) In this part, clinical interviewing regarding client’s background and issues will be
conducted by psychiatrist or psychologist. (b) Relevant information that will be asked including (i) History of Bipolar Disorder (when it started, duration that it has lasted, the severity, recurrent or new episodes) (ii) Treatment history of Bipolar Disorder (iii) Medical and family history (especially history of having Bipolar Disorder) (c) Family members or significant others will be interviewed especially if clients are children or adolescents.
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2) Psychological Evaluation In this phase, psychiatrist and psychologist (a) will check the presence, severity and duration of symptoms by using clinician-rated and/or semi-structured interview, self-report or/and other-report measures. (b) The level of functioning that client has and the pervasiveness of impairment in daily functioning on social and occupational domain. (c) Mental Status Exam may be used to obtain information regarding whether clients’ Speech, thought pattern and speech have been affected by bipolar disorder.\ (d) Other areas of evaluation including other psychiatric disorder, drug and alcohol use. This is detect comorbidity, at the same time taking drug and alcohol into consideration in judging whether these substances affect clients’ bipolar . 3) Physical examination In this phase, clinician will refer clients to do physical examination to determine or rule out that the clients’ bipolar disorder is due to general medical condition (such as hypothyroidism). II. Types of Assessments
As there is no biological marker for Bipolar Disorder, the diagnosis is based on examination of symptoms and potential medical explanation for those symptoms. Diagnostic and assessment tools are used to examine the presence and severity of symptoms. Structured diagnostic tools are needed to enable comorbid conditions to be detected (Zimmerman & Mattia, 1999 as cited in Miller, et al., 2009). Formal and routine screening on individual with history of major depression also important as many of them would meet diagnostic criteria for Bipolar Disorder, which normally be ignored by clinicians (Brickman, LoPicollo & Johnson, 2002 as cited in Miller, et al., 2009). As a result of improper diagnosis, serious consequences may occur as antidepressant treatment without mood-stabilizing medication can generate iatrogenic mania (Ghaemi et al., 2001 as cited in Miller, et al., 2009). Approaches that are normally used by clinician including: (a) Clinician-rated interview (b) Semi-structured interview (c) Self-report measures Clinician-rated Interview to Diagnose Bipolar Disorder 1) Youth M ani a Rating Scales (YM RS; Youn g, Biggs, Ziegler, & M eyer , 1978)
YMRS is a semi-structured interview conducted by trained clinician to assessed severity of manic symptoms. It is the gold standard scale for assessment of Bipolar Disorder (Perlis, 2010). The result is based on observation on patient during 30 minutes of interview and twoday patients self-report of manic symptoms before interview. There are 10 items covering core symptoms of manic phase (including mood, motor activity) and an item regarding patient insight in this measure. YMRS does not account for other DSM criteria of mania (including increases in goal-directed activity). Items of core symptoms (irritability, speech, thought content, and disruptive/aggressive behavior) are double-weighted as clinicians need to take patients’ cooperation during interview into account for observation part. Factor analysis of YMRS showed three factor, which is thought disturbance, overactive/aggressive behavior, and elevated mood and psychomotor symptoms (Double, 1990). Baseline score for mania is YMRS=12. YMRS has high inter-rater reliability (.93) and high correlation with other mania rating scales (.66 to .92) (Young et al., 1978) (Please refer to Appendix A).
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2) Bech-Raf aelsen M ani a Ratin g Scale (M AS; B ech et al., 1979)
MAS is similar to YMRS in its format. It has 11 items as well and cover classic manic symptoms (with five- point rating scale in which 0 means “not present” and 4 means “severe”). It has excellent internal consistency, interrater reliability and strong correlations with more lengthy measures of manic symptoms (Licht & Jensen, 1997). It can be used to assess effectiveness of treatment programme as it can detect changes in symptoms after intervention (Bech, 2002) (Please refer to Appendix B). The score interpretation is as following: 0-5 6-9 10-14 15+
no mania hypomania (mild) probable mania definite mania
Semi-Structured Interview to Diagnose Bipolar Disorder 1) Stru ctured Cli ni cal I ntervi ew for DSM -I V (SCI D; Spitzer, Wil li ams, Gibbon, & F ir st, 1992)
SCID is designed to assist diagnosing of Bipolar Disorder base on DSM-IV diagnostic criteria. It is divided into modules to cover different diagnoses, which allows clinician to 1. tailor the interview so that relevant diagnoses can be captured. It provides interview probes, symptom thresholds, and information about exclusion criteria to assist clinician in the process of diagnosis. In this semi-structured interview, probes that cover core symptoms are ready to guide clinician to collect symptoms information. Clinical judgments are needed to make symptoms information more reliable. SCID’s bipolar disorder module has good interrater
reliability (in international multisite trial and 10 major trials) (Williams et al, 1992; Rogers, Jackson & Cashel, 2001 as cited in Miller, Johnson & Eisner, 2009). SCID demonstrated adequate to excellent reliability for current and lifetime diagnoses, ranging from .64 to .92 (Williams et al., 1992 as cited in Miller, Johnson & Eisner, 2009). Compared to other standard clinician interviews, it has higher percentage of agreement with the gold standard (Basco et al., 2000 as cited in Miller et al., 2009). However, SIDS cannot accurately detect Bipolar II Disorder compared to expert clinician interview, probably because of of the subjectivity of definition (limited severity in hypomania episode (Miller et al., 2009) (Please refer to http:// support.infotechsoft.com/aspect/demo/SCID.pdf for the items and more information) 2) Schedul e for Af fective Di sorders and Schi zophr eni a (SAD S; E ndi cott & Spitzer , 1978)
SADS is designed to assist diagnosing of Bipolar Disorder base on Research Diagnostic Criteria (RDC), which are stricter and more likely to yield a diagnosis of Schizoaffective Disorder if psychotic symptoms are present in individuals. Similar to SCID, SADS contains interview probes, symptom thresholds, and information about exclusion criteria that assist clinician. Probes in SADS focus on most recent episode and as well as assist in obtaining a broad overview of past episodes. SADS has good to excellent reliability for both symptoms and diagnoses (Andreasen et al., 1981). It has demonstrated good interrater reliability and good test-r etest reliability when it is used to measures adult’s Bipolar Disorder over 5 to 10 years (Coryell et al., 1995; Rice et al., 1986 as cited in Miller, Johnson & Eisner, 2009). Within United States, it has demonstrate good validity in capturing diagnoses across different cultural and ethnic group (Vernon & Roberts, 1982).
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Similar with SCID, SADS has demonstrated low reliability in detecting Bipolar II Disorder. The ability to enhance detectability may be improved by starting measurement with question about behavioral activation and rise in goal-directed behavioral compared to mood (Akiskal & Benazzi, 2005). However, it is still waiting to be validated. SADS also has another subscale (SADS-C), which is used to assess current severity of manic symptoms. It has a good interrater reliability and strong correlations with other interview to assess manic severity, such as MAS (with r=.89) (Johnson, Magaro, & Stern, 1986). However, there is no adequate factor analytic support that tested item loading for SADS-C (Swann et al., 2001) (Online Adult version is not available. Please refer to Endicott & Spitzer, 1978 original article for more information or by grasping idea through kids version of SADS via http:// www.sign.ac.uk/pdf /sign82.pdf) (c) Besides that, it is advised that clinician should consider the following factors during diagnostic interview to differentiate whether clients are having Bipolar Disorder (especially Bipolar II) or Unipolar depression. According to PsychiatryTimes (n.d.), clients are more likely to having Bipolar Disorder compared to Unipolar Depression if below factors exist: (i) Prepubertal onset of symptoms (ii) Postpartum symptoms onset (iii) Brief duration of depressed episodes (iv) Seasonal pattern (v) High frequency of depressed episodes (vi) Multiple antidepressant failures (vii) Nonresponse, rapid response or/and erratic response to antidepressant treatment (viii)Dysphoric response to antidepressant treatment, with agitation and insomnia (xi) Family history of bipolar disorder (xii) Unstable interpersonal relationship in the past (xiii) Having vocational problem frequently (xiv) Responsibility in committing legal issues frequently (xv) Alcohol and drug abuse Self-Report Measures that Assess Severity of Bipolar Disorder 1) Bi polar Spectru m D iagnostic Scale (BSDS; Ghaemi et al ., 2005)
BSDS is a self-report scale that have 18 items to be checked and one item to be rated. It is meant to detect the likelihood of respondent to have bipolar disorder. It is sensitive in detecting the presence of Bipolar Disorder, including Bipolar I and II, with sensitivity=0.75 (Ghaemi et al., 2005). It is able to distinguish unipolar major depressive disorder from bipolar disorder, with the specificity=0.85 (Ghaemi et al., 2005). The 18 items are descriptive sentences that describe mood and symptoms of bipolar disorder, while the one item to be rated is to check how close the descriptive sentences describe the client. One check in each item is worth 1 point, and addition points will be required to be added to rating on last item (i.e. Add six points for ‘‘fits me very well,’’ 4 points for ‘‘fits me fairly well,’’ and two points for ‘‘fits me to some degree’’) (Please refer to Appendix C for items). The interpretation of
total score is as following: 0 – 6 Highly unlikely 7 – 12 Low risk 13 – 19 Moderate risk 20 – 25 High risk 2) M ood Swin g Questionn air e (M SQ; Parker, 2008)
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MSQ is a 27-item self-report measure that screens whether client has unipolar depression or bipolar disorder. The scales divided into 4 phrases: The first phrase tests whether client has more than 4 symptoms of depression. If they answer yes, they are required to proceed to question 2, which ask whether client experience mood swing. If they answer yes, they are required to move to question 3, which ask whether client’s experience different hyper in
manic phase compared to euthymic phase. If clients answer yes, they are required to proceed to question 4 that has 24 items asking the experience of “u p” as 0=no more than usual, 1=somewhat more than usual, and 2=much more than usual. If client score 22 or more, there is 80% probability that the client has bipolar disorder. It has high level of sensitivity= 0.81 and high level of specificity= 0.91 (Please refer to Appendix D for items). 3) H ypomani c Check L ist (H CL -32R1; An gst, et al., 2005)
HCL-32R1 is a screening tool to detect hypomanic symptoms in clients with diagnosis of depression (such as Major Depressive Disorder). The first question is used to assess whether client’s emotional state has effect on answers given in 32 items which consist hypomanic symptoms and will be presented later. The second question is used to assess client’s affective
temperament. The third question consists of 32 items that reflect hypomanic symptoms. These 32 items can be separated into 2 subscales, which are active/elevated and irritable/risktaking. While question 4 to 7 consists of items ask about how hypomanic symptoms affect daily life, how significant others react to them and days they spent in “high” during the past 12 months. If client score 14 or more “yes” to 32 items in question 3, the client may has
potentially developed bipolar disorder. This require clinician to use clinical judgment to further consider answers in question 1,2, 4 to 7 in judging whether client has bipolar disorder (Please refer to Appendix E for items). 4) General B ehavior I nventor y (GI B; Depue et al., 1981)
GBI is used to identify lifetime diagnoses of Bipolar Disorder, syndromal and also subsyndrmomal affective tendencies in clinical and nonclinical populations. It has several version, including brief version and parent-report version for children and adolescent population. GBI consists 73 items cover lifetime tendencies to experience depressive symptoms, hypomanic symptoms and biphasic (tendencies for mood states to fluctuate from extremely high to extremely low). It has high internal reliability (alphas exceeding .90), good test-retest reliability (exceeding .70), strong predictive validity (through biphasic & hypomanic items), adequate convergent and discriminant validity across various samples (Youngstrom, 2007 as cited in Youngstrom, Murray, Johnson & Findling, 2013). The brief version (with 14 items) has also demonstrated high internal reliability (.83 & .95), strongly correlated with original version and good construct validity (Youngstrom, Murray, Johnson & Findling, 2013) (Please refer to Appendix F for items). 5) M ood Di sorder Questionn air e (M DQ; H ir schfeld et al., 2000)
MDQ is a brief self-report screening instrument that consist 3 main questions: first question which consists 13 items of Bipolar Disorder symptoms, second question which asks whether individual experiences the symptoms in the same period of time, third question which asks the extent of the symptoms causing problem to the individual. Positive screening requires an individual to say “YES” to at least 7 items in Question 1, “YES” to Quest ion 2 and “Moderate Problem” or “Serious Problem” in Question 3. MDQ is best at screening Bipolar I
Disorder but not Bipolar II and Not Otherwise Specified Disorder. It has good internal consistency, good one-month test-retest reliability and good to excellent sensitivity (.73 t o .90) in differentiating bipolar and unipolar disorder in clinical samples (Weber Rouget et al., 2005). However, this is not the case for community samples. It has good predictive validity in
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assessing functioning impairment and suicidal ideation in primary care setting (Das et al., 2005). Therefore, it is more suitable to be used to screen patient who has existing psychopathology compared to nonclinical samples (Miller, Johnson & Eisner, 2009) (Please refer to Appendix G for items). 6) Al tman Self -Rating M ania ( ASRM ) (A ltman, H edeker , Peterson, & Davis, 1997)
ASRM is a 5-item scale measuring mood, self-confidence, sleep disturbance, speech, and activity level of individual over the past week. The total scores ranging from 0-20, in which the cut-off score is 5.5. Its advantages are good sensitivity and specificity, and have adequate internal consistency and concurrent validity with SADS, YMRS and CARS-M (Young et al., 1978). However, its weakness including covering less symptoms than other mania scales (Please refer to Appendix H for items). 7) Self -Report M anic I nventory (SRM I ; B r auni g et al, 1992)
SRMI is a 47-item true-false measures. It assesses symptoms similar to diagnosis criteria of DSM. It has a good internal consistency and discriminant validity (Braunig et al., 1996 as cited in Miller et al., 2009). Its advantage is high sensitivity to change. However, it is not suitable for inpatient due to setting as it was originally designed for outpatient. 8) Th e In ter nal State Scal e (I SS; Bauer et al., 1991)
ISS is a 17-item scale that differentiate mood state and tracks manic and depressive symptoms. It has 4 subscales, which are activation (item 6, 8, 10, 12, 13), well-being (item 3, 5, 15), perceived conflict (item 1, 2, 4, 11, 14), and depression index (item 7, 9). However, it measure arousal more the manic symptoms. It has scoring algorithms for vary substantially across studies, with different mean and standard deviaton of score distribution (Altman et al., 2001). It is sensitive to decrement of symptoms, but less sensitive to manic symptoms at the time of hospitalization (Altman et al., 2001). For depression, the score that is <125 in well being is considered as having depression; while for mania/hypomania. The score that is >125 for well-being and activation<200 is considered as having manic/hypomanic episode (Please refer to Appendix I for items). Self-Report Measures that Assess Depressive Episodes in Bipolar Disorder 1) H amil ton Rating Scale for Depr ession (H RSD; H amil ton, 1960).
HRSD is a 17-item scale observer-rated measurement. The scale cover the aspects of cognitive, behavioural and somatic aspects of depression. Clinicians are required to enter all related clinical information when completing the ratings. It has moderate to high inter-rater reliability (r= 0.57-0.63), high test-retest reliability (r= 0.81), high concurrent validity with clinician-rated measures such as Montgomery – Åsberg Depression Rating Scale (r=0.69 to 0.90) (Hamilton, 2000 as cited in Cusin, Yang, Yeung & Fava, 2009) (Please refer to Best Practice Workbook of Depression for the items). . The score interpretation is as following: 0-7 None/minimal depression 8-17 Mild 18-25 Moderate 26+ Severe 2) Beck D epr essi on I nventor y-I I (Beck, et al., 1996)
BDI-II is a 21-item self-report inventory that measures severity of depression. This inventory measures 3 aspects of depression, which are somatic, cognitive and behavioral aspects. The
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time frame is the last two weeks. It has high internal consistency (Cronbach’s = o,84), high test-retest reliability (r= 0.75), strong correlation with construct-related scales, and was sensitive to change (Kühner, Bürger, Keller & Hautzinger, 2007). It is important to measure client’s depression severity if client is in depressive episodes before come out with suitable treatment plan (Please refer to Best Practice Workbook of Depression for the items). The score interpretation is as following: 0-13 Asymptomatic 14-19 Mild depression 20-28 Moderate depression 29+ Severe depression 3) Th e Beck H opelessness Scale (B H S; B eck et al., 1974).
BHS is a 20-item self-report to measure client’s negative attitude and perceptions about the future. It is reported that hopelessness is better in prediction of suicide compare to depression. Score more than 9 in this scale indicate suicide ideation (Beck et al., 1985). It has been reported as having high internal consistency (alpha = .97), good test-retest reliability (r = .81), and good concurrent validity with scales assessing depressive thoughts such as automatic thoughts questionnaire (Bouvard, Charles, Guérin. Aimard & Cottraux, 1992). It is important to measure whether client is high in hopelessness so that proper intervention can be done to prevent suicide and other possible detrimental consequences when client is in depressive episodes (Please refer to Best Practice Workbook of Depression for the items). The score interpretation is as following: 0-3 normal range 4-8 mild 9-14 moderate 14+ severe 4) Th e Beck Scale for Sui cide I deation (BSI ; B eck & Steer , 1991).
BSI is a 21-item self-report inventory to assess and detect severity of suicide ideation in clients. It is a screening instrument that indicate suicide ideation rather than predicting eventual suicide. It has two parts: the first part consists of 19 items that gauge the severity of suicidal thought, attitudes and plan (with severity range from 0 to 2); while the second part of questionnaire consists of 2 questions that gauge about clients’ previous suicide attempt- the frequency and severity) for further information and are not counted in total score. The first five items in BSI is a screening items and if let said clients score 0 for item 4 and 5, then they can skip to item 10, and 21 if they have attempted suicide before. There is no cut-off score for BSI but any positive response in items should reflect suicide ideation that require clinician further investigation (Please refer to Best Practice Workbook of Depression for the items). Assessments that Measure Client’s Level of Functioning
1) Bi polar F un ctional Status Questionn air e (BF SQ; Goldberg et al, 2010)
BFSQ has been developed to assist evaluation of progress and treatment response exclusively for clients with Bipolar Disorder. It - Is a client’s self -report measures - Is aimed to provide evaluation that is more holistic based on clients functioning in eight domain: (a) Cognitive Function (b) Sleep (c) Role Functioning
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(d) Emotional Functioning (e) Energy/Vitality (f) Social Functioning (g) Personal Management (h) Sexual Functioning - Has good psychometric properties: high internal consistency, high test-retest reliability, strong convergent validity, significant discriminant validity across illness phases (please refer to Goldberg et al., 2010 original article for items and more information). 2) F amil y Bur den I nter view Schedule- Shor t F orm (F BI S/SF ; Tessler & Gamache, 1994)
- Is a clinician rated measurement, face-to-face or telephone interview - Interviewees are primary family caregivers of adults aged 18-64 - To measure burden related to caring for relative with mental illness (Bipolar Disorder) - 65 items, multidimensional approach, has five modules: (a) assistance with the activities of daily life; (b) supervision of bothersome or troublesome behaviors; (c) impact on daily routines; (d) financial expenditures; (e) worry on daily routines - Good psychometric properties: high internal consistency 3) Global Assessment of F un ctioni ng (GAF )
GAF is clinician-rated of clients’ overall functioning level. It is rated based on clinical judgment after considering impairments clients in psychological, social and occupational/school functioning (which are not related to physical and environment limitation). The scale ranges from 0 to 100, in which 0 indicate not enough information, while 100 indicate superior functioning. By starting from top (100) or bottom (0), clinician review each category 1 by 1 to see whether it match the clients’s symptoms severity or level
of functioning (either 1, depend on the more severe one). Once clinician has reached the category (let said 50) that best describe clients, compare with the category (let said 40) below and see whether it is more severe than clients’ symptoms severity and level of functioning. If
yes, choose that category (50 for example here) and rate from 0-9 (50- 59) to in which 0 indicates lower functioning/more severe and 9 indicates higher functioning/less severe. 4, Clin ical Gl obal I mpression for Bi polar Di sorder - Sever ity (CGI -BP-S)
CGI is used by psychiatrist to evaluate t he effectiveness of medication in reducing clients’ symptoms/treatment response based on illness severity (CGIS), global improvement of change (CGIC), and therapeutic response. Severity of illness is rated range from 1 to 7, in which 1 indicates normal and 7 indicates amongst the most severely ill patients. It has been shown to be a robust measure of efficacy in clinical drug trials (Guy, 1976). Other Supplemental Measurement that Assist Diagnosis and Case Formulation 1) D ysfu ncti onal Atti tude Scale (DA S; Revised by Power et al ., 1994)
DAS revised version specifically for Bipolar Disorder is a 24-item scale which is used to measure client’s self-evaluation, i.e. whether dysfunctional core belief exist regarding three areas that are interrelated to symptoms of Bipolar Disorder (both manic and depressive episode) . Three domains that are assessed by this scale is client’s dysfunctional belief in achievement, dependency and self-control. It is important to measure clients’ dysf unctional
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belief especially in gauging vulnerable factors contribute to manic and depressive symptoms, and in deciding the need to provide cognitive (behaviour) therapy for client (Power et al., 1994). There is no specific cut-off score for DAS, while higher score indicate higher dysfunctional belief. 2) Self -Contr ol Behavior Schedul e (Rosenbaum, 1980)
SCS is a 36 item self-report measures that assess clients’ application of cognitions in controlling physiological and emotional responses due to BD, problem solving skills, coping with harmful behaviour, ability to delay gratification, belief in own ability in controlling themselves when facing behavioural issues. The test-retest reliability of SCS is 0.86 (over four-weeks) with Cronbach’s = 0.78 to 0.86. It is important to know that how client cope with their lives so that appropriate intervention can be conducted to improve their coping skills. There is no cut off score in SCS, higher score indicate that clients use that particular coping skills more compared to others or have that kind of belief more. 3) M RC Social Perf orm ance Schedul e (H ur r y et al., 1983)
It is an observer-rated scale based on client’s report of their eight areas of social performance: Household Management, Employment, Management of Money, Child Care, Intimate Relationship, Non-intimate Relationship, Social Presentation of Self and Coping with Emergency. Clinician will rate the scale base on the actual behaviour and performances reported, with 0= fair to no problem, 1= serious problems on occasions but can sometimes manage quite well, 2=serious problem most of the time and 3= not able to cope at all. There is different cut off score for different scale. It has demonstrated good interrater agreement and reliability (Hurry et al., 1983; Lam & Wong, 1997). It is important to measure clients’ daily functioning as it assists diagnosis as well as formulation of treatment plan. (please refer to Appedix J) C. Predisposing, Precipitating, Perpetuating and Protective Factors I. Predisposing Factors
1) Family history Adult relatives of probands with Bipolar Disorder are 10-fold more likely to develop this disorder compared to relatives of controls (Merikangas & Yu, 2002). A twin study showed that monozygotic twin 3-fold more likely to develop this disorder compared to dizygotic twin if another pair of twin has Bipolar Disorder (Smoller & Gardner-Schuster, 2007 as cited in Yatham & Maj, 2010). By using Linkage disequilibrium (LD) approaches, researcher has found promising candidate genes that is related to development of this disorder, including G72 and brain-derived neurotrophic factor (BDNF) (Yatham & Maj, 2010). 2) Structural Abnormalities in Brain (Yatham & Maj, 2010) Abnormally reduced volume and grey matter density, synaptic abnormalities, decrease in neural and glial density in Anterior Cingulate; smaller Dorsolateral Prefrontal Cortex and Orbitofrontal Cortex were found in patients with Bipolar Disorder. However, further investigation are needed to determine whether these abnormalities cause, coexist or as consequences of Bipolar Disorder. Hypometabolism in prefrontal (especially in dorsolateral and medial orbital regions), temporal cortex, anterior and posterior cingulate have been found to be related to presence of Bipolar Disorder. In addition, hypermetabolism in deeper limbic system yield similar result.
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Decrease in anterior cerebral blood flow and metabolism decreases correlate with severity of Bipolar Disorder.
3) Personality Rash impulsiveness, which is unplanned impulsive behavior without foresee the effect, predicts occurrence and vulnerability of BD (Alloy et al., 2010). Hypersensitivity of Behavioral Activation System (BAS) is vulnerability factor for BD and predicts the course of BD - As those who have hypersensitive BAS, their BAS will be excessively activated when involving in rewards or goal striving and attainment events, which increase their activity levels that explain why individuals in hypomanic/manic can be very energetic and restless, and to the extent that their behavior can be unplanned. - Have higher level of autonomy, perfectionism, self-criticism. 4) Unpleasant and stressful life event (Beck, 1967 as cited in Alloy et al., 2006) Contribute to the development of faulty core belief and schema
Interact with individuals’ internal, stable and global att ribution style to develop BD.
II. Precipitating Factor
1) Event that has goal striving and attainment value (Johnson et al., 2008) Trigger those who have hypersensitive BAS. 2) Spring-summer seasonal condition (Lee et al., 2007). Probably correlated with longer photoperiod 3) High emotion expression communication style in the family (Kim & Miklowitz, 2004 as cited in Milklowitz, 2008). Family members are hostile, critical and over-emotionally involved in communication and interaction. Client who is from family which has negative affective style (AS; i.e. relatives having negative emotional-verbal behaviors when interact with client), and high emotional expressive (EE) are more likely to relapse compared to those who is from less negative AS and low EE (Miklowitz et al., 1988 as cited in Milklowitz, 2008).). 4) Childbirth (especially will cause relapse in those who have BD before pregnant) (Kumar et al., 2007) May be due to disruption of circadian rhythm after giving birth May be interact with genetic factor (happen higher among pregnant woman who has family history of BD). III. Perpetuating factor
1) Self-focused cognitive style (Alloy et al., 2009). (a) Rumination predicts the frequency of depressive episodes. (b) Increase private self-consciousness increase the likehood of onset of manic/hypomanic episodes. 2) Poor social and family support (Miklowitz et al., 2005). 3) Subsyndromal or persisting symptoms in between episodes (Judd et al., 2008). Cause poor functioning and thus increase distress level.
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4) Stigmatization Decrease help-seeking attitude (Link, et al, 1987 as cited in Lam et al., 2010). 5) Substance abuse (Salloum & Thase, 2000). 6) Antidepressant medication (Schneck et al., 2008). Those clients with either bipolar I or II 3.8 times more likely to experience rapid cycling than those who are not 7) According to Goodwin & Jamison’s Instability Model, it is an interaction of (a) individual’s vulnerability to disruptions of circadian rhythm
(b) taxing life events (b) medication non-compliance (c) social rhythm disruption, presence of social Zeitstörers (i.e. physical, chemical & psychosocial cue that disrupt circadian rhythm (Goodwin & Jamison, 1990 as cited in Swartz et al., 2010) Taxing life events disrupt the integrity of circadian rhythm. Medication noncompliance increase the vulnerability of those who have previously been diagnosed as having BD and have individual vulnerability to disruptions of circadian rhythm (Healey& Williams, 1989 as cited in Swartz et al., 2010). Cognitive error in misinterpreting energetic feeling (resulting from sleep deprivation) as personal positive characteristic increase activity engagement and thus further disrupt the circadian rhythm (and increase the severity of manic episode) (Healey& Williams, 1989 as cited in Swartz et al., 2010). IV. Protective Factor
1) Abstinence from alcohol and drug use (NAMI, 2008) 2) Structured schedule (NAMI, 2008) Regular rest time Appropriate schedule of recurrent social activities, make use of zeitgebers (i.e. social cues that entrains circadian rhythm. 3) Strong social support system (NAMI, 2008) From family, friends, professionals, self-help group 4) Regular exercise (NAMI, 2008) 5) Premorbid high IQ (Zammit et al, 2004) May protect against development of psychosis in BD. D. GENERAL OBJECTIVES OF TREATMENT FOR BIPOLAR DISORDERS AND EVALUATION
Base on Practice Guideline for the Treatment of Individuals with Bipolar Disorders, the general objectives of treatment are as below (APA, 2002): 1) Ensuring the safety of individuals with BD and others surrounding them (ensure that they bring no harm to self and others). 2) Encouraging and engaging outside providers, family members and support system to
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provide supports for individuals with BD. 3) Enhancing clients’ treatment adherence.
4) Creating awareness of stressors and patterns of activities and rest/sleep. 5) Assisting clients to anticipate, recognize and address the early sign of relapse. 6) Assessing, managing and evaluating functional impairments such as cognitive deficits, social relationship, occupational, living conditions and medical needs. 7) Educating clients about Bipolar Disorder. Treatment provided aimed at improving treatment adherence, motivation and mitigating the risk of relapse. 8) Addressing co-occurring behavioral and medical conditions such as substance disorders Evaluation of achieving objectives will be done based on types of intervention that clients undergo. However, in general, evaluation will be done on before or during termination phase, and follow up phase that varied across types of intervention. Domains that will be assessed for evaluation purpose are: (a) Presence of symptoms (b) Severity of symptoms (c) Duration of symptoms present (d) Extent of impairment on daily functioning caused by symptoms (e) Pattern of mood dysregulation (f) Comorbidity (presence, severity, duration, if applicable) (g) Suicidal ideation and risk (if applicable) E. WAYS OF MONITORING PROGRESS
Bipolar Disorder characterized as disorder involve constantly change in terms of clients’
mood. Therefore it is important to have tools that closely assists clinician, clients and their significant others to monitor their progress after started receiving treatment. Below are two of the common tools that assist monitoring: 1) NI M H prospective L if e-Chart Method (NI M H -L CM -p)
(a) It is a collection of prospective (current) data on course of illness and treatment that client with BD has received. There are retrospective Life-Chart as well to enable accurate diagnosis to be made, prediction of future course of illness and proper intervention. (b) People who rate. (i) Patient- for self-monitoring purpose (refer to Appendix K) (ii) Parent/caregiver (iii) Clinician (c) Descriptions. (i) The version for patient, caregivers and clinician, are basically the same. (ii) There is a horizontal line across the middle of chart that represent the baseline of BD (which is neither depressed nor hypomanic or manic- euthymia) and a special column for date/month (dateline). Above the dateline is where the hypomania and mania charted, while below the dateline is where the depression charted. This is to enable client, caregiver and clinician to see the mood fluctuation pattern across the month/ in the past few year. The severity of the mania and depression are rated base on the degree that the mood dysregulation causes functional impairment.
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(iii) Other information that need to be included are number of mood switch per day (ultradian) or per month (ultra-rapid), treatment (medication and psychotherapy), life event that affect the mood/mood changes, and comorbidity symptoms (with impact rating from -4 to +4, and 0 representing no impact). (d) Functions. Enable more precise recall of severity, duration, frequency and patterning in the previous month and comparisons of mood dysregulation pattern across the day, week, month and year for (i) Defining baseline course, monitoring the clinical response to treatment, and further sustained improvement and disruption of improvement due to breakthrough episodes (ii) Early detection and intervention of prodromal stage before full blown of relapse occur. (iii) Treatment planning for newly observed pattern. (e) Validity Convergent validity- significantly and strongly correlated with Youth Mania Rating Scale (YMRS, Gold standard), Inventory of Depression Symptomatology- clinican rated (IDSC) and Global Assessment of Functioning (GAF) (Denicoff et al., 2000). (f) Strength and Limitation Difficult to be used by clients and caregivers, but considered to be worthwhile across culture due to large amount of functions and advantage that it brings (Honig et al., 2001). Computerized version (Palmtop computer version) has been devised to resolve time-consuming issues (Schärer et al., 2002). 2) Chr onoRecord softwar e (Chr onoRecord Association , 2013)
(a) Similar to NIMH- Life Chart Method, it is a computerized software that assist client’s self-monitoring process. (b) People who rate. Client (c) Description (i) It is a 100-unit visual analog scale that has mood extremes of mania and depression. (ii) Client was trained before using and during that time, they had set an anchor points (which was the most depressed and most manic states that they ever experienced before), described the predominant features of the extreme state. This anchor points serve as a baseline for them to compare with mood everyday. (iii) Then, client are required to - Enter single rating that best describe their overall mood for the previous 24 hour, at the same time for everyday, without influenced by the previous day’s rating. - Review carefully the whole 24-hour period. - Besides mood, enter medication and treatment taken and the sleep data (d) Functions. Enable detailed assessment of frequency and mood dysregulation pattern, which allow (i) Comparisons of daily mood fluctuations and medications. This helps to monitor the effectiveness of pharmacotherapy and whether there is nuances of partial response. (ii) Encourage clients to be active participants in monitoring their own illness (with easy steps and time-saving method).
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(e) Validity Has convergent validity with Youth Mania Rating Scales (YMRS) and high accuracy in differentiating hypomania and mania (Bauer et al., 2008). (f) Strength and Limitation Able to increase client adherence involve as it is time-saving, more convenient and more straightforward (Bauer et al., 2004). However, information that is important to be monitor such as number of episodes in one day (for rapid cycling), impairment to the daily functioning, special life events that happen on particular that can explain the mood fluctuation that are crucial for understanding clie nts’ mood fluctuation and evaluating effectiveness of treatment options are not recorded. F. INTERVENTION OPTION Pharmacological Treatment
Drug Lithium carbonate & Lithium sulphate
Function Prevent mania & depression
Period to administer -During acute mania and maintenance phase -For BD I & II
Valproate
For relatively severe BD & behavioral issues (eg. irritability)
-During acute mania phase
-For BD I -For BD II with rapid cycling Lamotrigine Stabilize mood, -During maintenance effective in phase preventing mania -For BD I & depression -For BD II with alcohol dependence, rapid cycling Carbamazepine Stabilize mood in -During acute mania acute mania & & mixed phase mixed episode
Olanzapine
Selective Serotonin Reuptake
Remove symptoms Stabilize mood
Side effect Initial: Diarrhea, vertigo, muscle weakness, dazed feeling, tremor, polyuria, polydipsia & etc. Long term: hypo/hyperthyroidism, goiter, mild memory or cognitive impairment & etc. Initial: Increased appetite & weight gain & etc. Long term: Liver dysfunction & etc. Skin rashes, drowsiness, headache, insomnia, blur vision & etc.
-For BD I & II -During acute mania & mixed phase
Initial: Dizziness, drowsiness, gastrointestinal symptoms & etc. Long term: kidney abnormalities, liver dysfunction & etc. Headache, insomnia, dizziness, agitation, and etc.
- For BD I - During acute depressive episode
Nausea, agitation, nervousness & etc.
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21 - For BD II
Somatic Treatment- Electroconvulsive Therapy (ECT)
ECT is a procedure where specific region of brain such as prefrontal cortex, orbitofrontal cortex, and connections to limbic structures are induced seizure. It will only be used under condition as below: (a) Mania is treatment resistant (b) Severe suicidality (c) Presence of psychotic symptoms (d) Catatonia (e) Food refusal that cause severe nutritional deficiency (f) History of responding positively to ECT (g) Risk of ECT is lower than other treatment’s risk Psychoeducation
An active and didactic presentation and education of information about an illness and ways to manage it. It can be done for individual or in group. 1) Objectives and ingredients of psychoeducation: Objectives Ingredients To create awareness (a) Work on denial by introducing medical model to client towards illness that can help them to decrease stigma and guilt, which then enhance their acceptance of treatment. (b) Work on barriers to effective treatment by providing information and generate discussion. To enhance adherence Educate clients about (a) Different types of psychotropic medication for BD. Review brand names of medication, explain differences of generic and brand names. (b) That pharmacological treatment is highly customized for individual. (c) The purpose of each medication and how a drug can serve more than one purpose. (d) Side effects of medication, and discuss strategies to deal with it. (e) Importance of monitoring serum levels (especially those who take lithium and also valproate & carbamazepine). (f) The signs of toxicity with medication (especially lithium). (g) Drug-drug and drug-food interaction (h) Appropriate administration of medication (eg. When to take, dosage). (i) Effectiveness of other psychotherapy adjunctive to medication (j) Ineffectiveness of non-tested treatment (eg. spiritual healing) To avoid substance misuse Educate clients about (a) The effect of taking alcohol and street drugs (b) The effect of harmless substances such as caffeine which can be misused by clients during subsyndromal and
BIPOLAR DISORDER
To detect early warning signs To encourage healthy habits
22 syndromal depressive stage to compensate their depressive mood. This is because these types of substances can trigger and intensify affective disorder episodes. Educate clients about (a) Warning signs (b) Strategies to prevent relapse (c) Strategies to cope with warning signs and symptoms Educate clients about (a) Sleep management (duration, strategies to sleep well). (b) Organizing daily activities in more structured and regular ways. *If client has serious issue in regular habits and routine, it is recommended to introduce Interpersonal and Social Rhythm Therapy (IPSRT).
2) Psychoeducation is more effective if: Polarity that client is in Clients are in manic episodes (Miklowitz, 2008). Conditions that client is in It is more effective if delivered during maintenance phase (for both individual and group) (Collon & Berk, 2010). Therapist training (a) Have clinical experience handling group and BD clients, trained in social skills and bipolar psychoeducation (Collon & Berk, 2010).. (b) If it is in group, more than 1 therapist can be more effective (Collon & Berk, 2010). Group size (for group Optimal size is between 8 to 12 clients (Collon & Berk, psychoeducation) 2010). Group participants (for group (a) Euthymic & stable in the beginning of programme psychoeducation) (b) Balance of gender (c) Balance of number of BD I & BD II clients if combination of group is necessary. (This is to avoid BD II clients from being defensive and denial, and claim that they are not as severe as BD I clients which lead to drop out) (Collon & Berk, 2010). 3) Limitation: (a) Efficacy of psychoeducation will be reduced if clients have greater number of previous episodes (Colom et al., 2010). (b) Those who perceive their previous manic episodes as positive took longer time to recover (Sorensen et al., 2007). (c) Dropout rate of those who have external locus of control is high as they perceived that psychoeducation cannot help them (Even et al., 2007). Interpersonal & Social Rhythm Therapy (IPSRT)
1) It has three types of intervention, in which each intervention rest on different theoretical constructs and different goals: Intervention Psychoeducation
Theoretical constructs Tripartite goals - Goodwin & Jamison’s instability Support medication adherence
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23
Social Rhythm Therapy
model (refer to perpetuating factor Minimize impact of disruptions mentioned in Etiology). by life events on social rhythm - Presence of social Zeitstörers in disrupting circadian rhythm integrity
Interpersonal Psychotherapy
Psychosocial & interpersonal factors associated with onset of mood disorders in biologically vulnerable person, which then affect their interpersonal coping skills.
Solve interpersonal difficulties
In IPSRT, life events (for example, daily schedule, interpersonal disputes) are viewed as source of mood dysregulation and potential triggers of rhythm disruptions. Therefore, therapist role is to help client adapt to change and find healthy balance between stability and spontaneity as clients with bipolar disorder may be destabilized when minor change. Part 1: Social Rhythm Therapy
This therapy is developed based on the idea that stable daily rhythm improve mood stability. By promoting regular and rhythm-entraining social Zeitgebers and manage negative impact of disrupting Zeistörers. There are three large steps in this therapy, which are Step 1: (a) Client will be required to complete the Social Rhythm Metric (SRM) (refer to Appendix L). (b) It is a self-report form to record daily activities, whether each occur when client is alone or with presence of other, and whether the situation involve significant amounts social stimulation (which is interactive or quiet). Client is also required to report their mood each day in SRM (c) Client will be required to complete SRM weekly and the first three to four weeks will be used as the baseline social rhythm Step 2: (a) Then, therapist and client will review the SRM together. (b) This is to find out: (i) stable and unstable daily rhythm; (b) client’s behavior that negatively affect the rhythm stability. Step 3: (a) Next, therapist will work with client to stabilize the social rhythm through graded and sequential lifestyle changes. (b) In this step, client are required to identify and build their (i) Short term goal (which is started changing small unhealthy behavior, such all stopping all midnight activities). In order to achieve this, client will be required to change their social behavior and health-related behavior to ensure he is achieving the short-term goal (such as only do housework in the morning, stop eating
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supper). (ii) Intermediate goal (which is built on short-term gains and establish new social cue, such as attending gym in the afternoon). The idea here is to help client to establish a regular time schedule although it requires them to come out from schedule they are comfortable with, by gradually. (iii) Long-tern goal (which is encouraged them to find a long-term commitment to allow them to maintain a more regular schedule, such as choose office work rather than freelance job so that they have regular working time and the time for other daily activities can be fixed and structured). Other factors that therapist will take into consideration when monitoring and help client to come out with different goals and establishing regular schedule: (a) Frequency and intensity of client’s social interaction (to help them to balance between social and individual time to avoid being under/overstimulated by social interaction). (b) Connections between mood and activity (to help client to set activities according to episodes and phases to enable better mood regulation). Follow-up step: (a) Throughout the course of treatment, therapist and client will continue reviewing SRMs. Therapist will work with client in identify social rhythm goals after one goal has been achieved, and help them to address obstacles to change. (b) In this therapy, SRMs play the roles as self-monitoring tools for clients (monitor their mood and activities changes that can indicate relapse), and also to measure and evaluate therapeutic change. Part 2: Interpersonal Psychotherapy (IPT)
Step 1: Therapist will conduct Interpersonal Inventory to explore (a) important individuals in clients’ life (either mentioned or not) (b) quality of relationship in clients’ current and past life systematically
Step 2: Therapist comes out with interpersonal case formulations which include (a) clients’ diagnosis
(b) type(s) of interpersonal problem and its relations with symptoms exacerbation. Step 3: Customize treatment according to types of interpersonal problem, which are described as the following: Interpersonal Problem Grief
Role Transition
Descriptions
Treatment Focus
Loss of significant individual in life and related to symptoms (only when the person has passed away)
Facilitation on mourning process (encourage expression, help them recognize distorted memories of the relationship). Facilitation in developing more realistic views of both old and
Change in one’s social role
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Grief for the lost of healthy self
Symbolic loss of self after having BD
Interpersonal Role Dispute
Nonreciprocal expectations in intimate relationship
Interpersonal Deficits
Long history of unsuccessful relationship and isolation
news roles (resolve idealization of old role and devaluing of new role), acquire new skills to master new roles Facilitation on mourning of losses, recognition of own strengths and encourage setting new realistic goals. Facilitation in identification of dispute, alteration of role expectation and communication pattern, development of change plan. Facilitation in identification of cause, and building up interpersonal skills
Integrating Psychoeducation, Social Rhythm Therapy and Interpersonal Therapy Three types of therapies will be conducted concurrently. However, the emphasis on three therapies will be different according to the phase of treatment and acuity of client’s
symptoms. Phase
Psychoeducation
Initial
(a) Gather information
Social Rhythm Therapy Step 1
of clients’ background
especially interpersonal disputes and disrupted daily routines happened before previous and current episodes. (b) Identify triggers event, vulnerabilities & conceptualize interpersonal life. (c) Use IPSRT paradigm to assist client to see relations amongst their interpersonal events, social rhythms & episode onset Intermediate Educate the importance Step 2 & 3 of stability, negotiate how much stability is possible to minimize relapse while have “safe” spontaneity in
other area to stimulate themselves in proper manner.
Interpersonal Therapy Step 1 & 2 (if client is unstable, either hypomanic or manic, case formulation may not be done, emphasize more on psychoeducation first
Step 2 (if unable to complete in initial phase) & 3
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Maintenance (a) Consolidate treatment gains, optimize interpersonal functioning in absence of syndromal illness and prevent recurrence. (b) Crisis intervention if needed. (c) Educate the importance of maintaining regular social rhythms, reinforcing importance of practicing skills. Termination (a) No specific time for termination, depends on individual preferences as well as therapist’s clinical judgment.
(b) Should be done very gradually, four to six-monthly sessions for followup before termination. (c) Review, reflection and encouragement. (d) Identify important resources if symptoms worsens after termination phase. Factor influence choice of treatment and effectiveness: Polarity that client is in Clients are in depressive episodes (Miklowitz, 2008). (However, if client is in hypomanic/manic episode, ensure that they are stable under medication first before move on). Conditions that client is in Best to initiate during acute phase rather than recovery phase so that can be more effective in delaying relapse (Miklowitz, 2008). Limitation: (a) Effectiveness drops after 2 years from termination (Frank et al., 2008). (b) IPSRT is more effective for women than men (Frank et al., 2008). Cognitive Behavioral Therapy Lam, Jones & Hayward (2010)’s programme
1) Main objectives: (a) Increase compliance to medication (b) Recognize prodomes (c) Prepare for and delay relapse (d) Self-management during relapse and mood fluctuation. 2) In total, 20 sessions in 3 stages. 3) Before getting started, it is important to conduct pre-therapy assessment to gain baseline data or clients’ issues that is crucial and/or can be changed by intervention, such as cli ent’s dysfunctional attitude, use of cognitive control of behavior, mood state, performance, suicidality. 4) Outline of treatment Stage Topic Initial Education, Development of (1-5 Therapeutic Alliance sessions) Illness history
Method (a) Introduce diathesis-stress model (b) Explain structured approach & introduction of agenda in beginning of each session. (a) Review client’s illness history and
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27 use them to educate client regarding symptoms (b) Help client generate chart of illness history (which will be used as reference)
Self-monitoring
Goal setting
Intermediate Activity Schedule (5-16 sessions)
Thoughts monitoring and challenging
Behavioral experiment
Dysfunctional assumptions
Early warning signs
Medication compliance
(a) Emphasize client’s active
participation and role of selfmonitoring (b) Teach client how to monitor mood, thoughts & activities throughout and after all sessions. (a) Help client generate a list of goals, analyse steps towards goals (b) Help client identify discuss obstacles and how to continue goals despite presence of symptoms. (a) Teach client to record down their daily activities and identify factor that related to mood change (to identify the antecedent of mood swing) (b) Help them plan appropriate activities and regular schedule. (a) Identify what types of thoughts (positive and negative) are prominent in which episodes (manic & depressive) (b) Provide example of challenges, introduce and review homework together, as well as obstacles. (a) Introduce & explain medication incompliance. (b) Review and tackle incompliance reason by having experiment outside therapy session. (a) Discuss importance of addressing, relate thinking with dysfunctional assumptions (b) Demonstrate how to challenge it and review with client. (a) Identify information such as history, activity schedules, mood ratings, thoughts monitors that may indicate relapse (b) Discuss coping strategies. (a) Discuss about advantages & disadvantages of medication, cost benefits of medication incompliance, importance of client’s role in
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Final (16-20 Review sessions) Self-management
28 managing own medication. (a) Assess extent of client internalize the cognitive approaches (b) Discuss its benefits in terms of relapse prevention. (a) Review on self-management practice and issues raised (b) Emphasize the importance of sleep, diet and routine.
Consequences of Mental Health History
Discuss issues of stigma, guilt and grief related to their sensation seeking behavior or resulting from labelling, and their effects on family relationship Summarize Main Points of Therapy Help client to develop therapy notes for future use 5) Homework that has been assigned to client will be review together with them by therapist in the next session to ensure client practice and able to overcome obstacles that deter them from practicing (Lam et al., 2010). 6) Termination of CBT is normally scheduled and structured. However, additional session are allowed depend on therapists’ judgment and clients’ ability to follow the flow. Post -treatment assessment can be done before termination to assist therapist’s judgment, especially on assessment that have been done before therapy sessions commence (Lam et al., 2010). 7) Factors influencing the choice of treatment options and treatment effectiveness: Timing of therapy being introduced - More effective when client is in depressive episodes (Miklowitz, 2008) - Is not effective if client is manic and overly depressed (Lam et al., 2010) - More effective if client is in recovery rather than acute phase (Miklowitz, 2008). Collaboration - More effective if client can participate actively, and at least have average cognitive competency (and without any impairment) (Lam et al., 2010). Medication consumption and adherence - More effective if client comply to medication (Lam et al., 2010). Client’s motivation to change and pra ctising - More effective if client have higher of skills acquired motivation to change and commitment in skills practicing (Lam et al., 2010) 8) Other manuals that are available to assist therapist in conducting CBT programme with client with Bipolar Disorder: (a) Basco & Rush (1996) (b) Newman et al. (2001) Here are the similarities and differences across programme which can assist therapist to make decision:
BIPOLAR DISORDER Lam’s programme
29 Basco’s programme
Newman’s programme
Similarities
-All deal with BD in maintenance rather than acute phase - Strongly emphasize on psychoeducation, medication adherence, early warning signs, employment of cognitive behavioural, interpersonal approach
Differences in Strengths
- Employ classical cognitive approach - Emphasize relapse prevention in traditional psychoeducation approach
- More explicit & detailed in implementation & evaluation
- More discussionoriented - More flexible
9) In addition, CBT also exist in group format that employ similar outline and method as individual session. 10) Limitation of CBT (Association for Behavioral And Cognitive Therapies, 2013): (a) Require high commitment and motivation from clients in practicing the skills learned in the session in their daily life. (b) Not effective for those who believe that hypomanic is their personal attributes rather than metal illness (Lam et al., 2005c). (c) Effectiveness in reducing relapse rate does not last for longer than one year (Lam et al., 2005b). Family-Focused Treatment (FFT; Miklowitz & Goldstein, 1990)
1) Background & Issues The relationship between client with BD and their family members are often characterized as emotional inaccessible, rigid, conflictual and disrespectful (Cohen et al., 1954 as cited in Milklowitz, 2008): This can be caused by, for example (Kim & Miklowitz, 2004 as cited in Milklowitz, 2008): (a) existing high expressed emotion attitude by the family which can be the risk factor of predisposing client to BD (b) client externalizes his behavior when being criticized and triggered by intrusive statement, which ended up both parties constantly involved in conflict and arguments. (c) family and client resulting from clients’ BD issues have communication deviance, in
which the clarity of communication is low and thus trigger disputes. (d) family’s unrealistic expectation on client’s recovery and their role in the family despite BD) (e) client’s unpredictable mood swings that is difficult to be distinguished from personality and symptoms (f) possible negative consequences that family need to bear due to clients’ risk -taking behavior and impulsivity According to Miklowitz (2008), these issues were able to precipitate recurrence of BD. As a result, FFT was developed by Miklowitz & Goldstein (1990) to address abovementioned issues. 2) Target individuals: Client and their family/significant others
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30
3) According to Miklowitz (2008), FFT is suitable for clients who are (a) Having Bipolar Disorder as their primary diagnosis (if they have other comorbid like substance dependence). (b) Acutely-ill - Regardless of setting that the client is in. - It is important to tailor educational materials to suit the client’s severity and setting they are in. (c) Comorbid developmental disabilities or neurological conditions - Should include them although they have cognitive impairment by tailoring educational materials to assist them in understanding their own issues with the presence of their family. (d) Not complying with medication - Should emphasize that FFT is not a substitution of pharmacotherapy. - Need to focus on this part if client does not take medication due to lack of understandings of the function of medication or use medication incompliance as a mean to express their anger and rebel towards family members who attempt to control them. (e) Presence of family members who have frequent contact with BD client and assume the role of closely monitoring clients’ (their family member with BD) health.
4) Issues that therapist need to be aware of before starting (Miklowitz, 2008) (a) Settings: Home vs. Clinic (i) Choose home if - there is a large number of family members involve - generalization of certain communication skills are more important (ii) Choose clinic if - family members worry about stigmatization issue - avoid family members from having wrong perception that therapist need them more than they need therapist (encourage assuming of responsibilities and selfinitiated change rather than dependent on therapist to change) (b) Clinician Cotherapy team is more effective - Observation on each family members can be done more thoroughly - Identification issues or themes that another clinician has missed (cross-check) can be done - Both more and less vocal members can be attended to. 5) Before therapy started, a functional assessment will be conducted to (a) Support that the diagnosis of Bipolar Disorder is correct. (b) Obtain systematic psychiatric history, from both patient and their significant others. (c) Measure family’s distress level (d) To gain information to determine which family’s resources and skills , domains of
managing the disorder, communication and solving problem can be enhanced. 6) Important domains that will be covered in functional assessment including: (a) Diagnostic Interview (b) Prior Course of Illness (from client and significant others’ point of view)
(c) Premorbid Functioning
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31
(d) Family Interaction by (i) Giving scenario/topic and observe how client discuss with their significant others (ii) From the observation, determine communication assets and deficits that client and significant others have. (e) Prior knowledge of Bipolar Disorder 7) Arrangement of stages of FFT according to client’s illness phase and summary of what will be done in each stage (Miklowitz, 2008). Illness phase Stage Objective Description Acute Rapport - Developing therapeutic building & relationship assessment - Assessment Stabilization Psychoeducation - Having more (a) Educate family about understanding about (i) symptoms, differential etiology of BD. diagnosis, comorbidity, - Integrating experience course, treatment, selfwith clients associated with management mood episodes in BD. (ii) how genetic & - Accepting the notion of biological vulnerability, vulnerability to future stress, individual coping episodes. protective factors interact to “cause” onset of BD - Accepting the need for mood-stabilizing medication for symptoms (b) Assist family to control. formulate Relapse - Differentiating client’s Prevention Plan personality and his/her BD. (i) Help family recall - Assisting client and his important information family in relapse such as previous periods prevention. of mood instability, sequence of trigger, early warning relapse signs, palliative measures (ii) Develop a plan which consists of action in preventing relapse such as ways to reduce stress triggers at home. Communication Enhancement Training (CET)
-Decreasing unproductive interaction among family members -Improving quality of exchanges.
Adopt role play method (coaching & shaping): (i) Teach family about expressing positive feelings, active listening, making positive request for changes in others’
behaviours & provide constructive feedback (ii) Give homework to record family’s efforts in
BIPOLAR DISORDER
Maintenance Problem solving
Termination
32 using & generalizing techniques learned in home setting. - Identifying areas of Assist family members to disagreement (i) Identify & define most - Generating, evaluating & pressing issues with BD implementing solutions client. - Focusing on behaviour (ii) Generate solution management strategies choices (iii) Evaluate pros and cons of solution choices (iv) All family members come together to a best solution (v) Develop implementation plan (vi) Practice problem solving (vii) Review whether plan reflect the objectives and is effective - Evaluate the effect of FFT Refer to below - Review course of treatment - Anticipate future problem By gauging whether - Evaluate future treatment clients and families need needs (a) More and different type of family treatment (b) Individual therapy (c) Desire to participate in support group Arranging follow up visit
Usually 3-6 months after termination and will (a) Evaluate client’s
clinical status (b) Check whether client obtain desired follow-up care (c) Check whether client need referral (d) Check the attempt of client reentering school or work and whether it is successful. 8) Prior to termination, evaluation of the effect of FFT on client and family will be conducted. The key domain that clinician will assess including whether they understand and able to generalize skills learned as listed below: (a) Nature of BD, factors that trigger recent episode
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33
(b) Client’s and family’s awareness of risk of full syndromal recurrences and subsyndromal
mood fluctuation. (c) Role of medication in treating acute episodes of BD. (d) Preventing recurrences by continuing medication. (e) Differences between enduring aspects of client’s personality, as contrast with sign and symptoms of BD. (f) Effective means of identifying and managing stressors. (g) Employing effective strategies for direct communication, problem solving, conflict management to maintain cooperative, positive and healthy emotional tone in family relationship. 9) Factors influencing the choice of current reatment options and treatment effectiveness: Polarity that client is in More effective when clients are in depressive episodes (Miklowitz, 2008). Conditions that client is in Best to initiate from acute phase (Miklowitz, 2008). 10) Limitation: (a) It requires great commitment from family. Therefore, it may not be feasible especially if family are financially unstable, significant others have mental disorder/general medical complication that require attention and assistant from other family members (Scott & Colom, 2008). (b) FFT only effective in improving BD clients who were from dysfunctional family (Miller et al., 2008). Third Wave Psychotherapy for Bipolar Disorder: Dialectical Behavior Therapy (DBT; Linehan, 1993).
1) Goals: (a) To reduce depressive symptoms (b) To reduce suicidal ideation (c) To improve mood regulation (decrease hypersensitivity to emotional stimuli, extreme emotional intensity and allow moderate return speed to baseline emotion state). 2) Phases, Modalities, Objectives, Topic and Method of Conducting Phases Modalities and Objectives Topic and method conducting Acute Family Skills Training (a) Psychoeducation - Family able to manage their (b) Four standard modules of DBT: own mood dysregulation before (i) Mindfulness they are competent to provide a (ii) Distress tolerance better environment for client to (iii) Emotion regulation recover. (iv) Interpersonal effectiveness - Using handouts, exercises and activities and applying new skills outside session. Individual Therapy Sessions (a) Psychoeducation (regarding DBT and - Client understand Bipolar and Bipolar Disorder) DBT better and adhere to (b) Four standard modules of DBT: treatment (i) Mindfulness - Clients are able to focus on (ii) Distress tolerance current emotion rather than (iii) Emotion regulation ruminating the past, control (iv) Interpersonal effectiveness
BIPOLAR DISORDER emotion better, assertive at the same time not jeopardize others, and withstand difficulties by replacing problem behavior with appropriate coping strategies -Clients are able to solve issues that trigger or prone them to relapse. Maintenance Family Skills Training & Individual Therapy Sessions Continuation
34 (c) Problem solving strategies (i) Understand function of behavior by conducting behavioral chain analyses for targeted problems. (ii) Identify alternative solution that is constructive (iii) Develop techniques that prevent future problem behaviors - Goals setting, using diary cards, handouts, exercises and activities and applying new skills outside session. - Consolidate gains by doing revision - Review skills application
3) Limitation: Limited evidence to support its efficacy on adult’s Bipolar Disorder, suitability for polarity and phase that clients are in (Richardson., 2010). Third Wave Psychotherapy for Bipolar Disorder: Mindfulness-Based Cognitive Therapy (MBCT; Tesdale et al.,2000)
1) Goals: To reduce depressive symptoms and suicidal ideation 2) Objective: (a) Enable client to view negative and suicidal thoughts and feelings as passing events and minimize important on it. (b) Enable client to be more open and ready to face difficulties and discomfort 3) Method of conducting: (a) Mindfulness medication during class. (b) Assigning homework exercise for client to practice on how to increase their non judgmental awareness of bodily sensations, feelings, thoughts, and behavior, and assimilate awareness skills into daily functioning. (c) Traditional CBT normally will be incorporated into treatment. 4) More effective when client is in depressive rather than manic episodes (Miklowitz et al., 2009). 5) Limitation: Inconsistent and limited findings about its effectiveness, suitability for polarity and phase that clients are in (Richardson., 2010). Other intervention besides psychotherapy Wellbeing plans
1) It is important to help client to develop a wellbeing plan to ensure clients are able to maintain and generalize coping strategies that they have learnt to gear towards remission and relapse prevention (Orum, 2008). 2) Step 1: Finding motivation To make this plan to be effective and long lasting, first of all, client should be the main character who decide the direction of plan, and clinician only play the role of assistance. Therefore before started, it is important to encourage and motivate client to develop and then
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35
follow the plan. These can be done by discussing the following to create insights and willingness to change in them: Topic Content of discussion Costs of illness Explore how the illness has negatively affected - sense of self - their life - their relationship Benefits of illness Explore how the illness has positively affected - sense of self - their life - their relationship Imagine life with fewer Discuss if they are able to learn to manage this illness and episodes (or with they can free from episodes for several years, what successful management) differences it will bring to - sense of self - their life - their relationship 3) Step 2: Encouraging client to involve others in their plan - In this step, help them to involve family members, friends or significant others that they can trust on and have frequent contact with them into development of treatment plan. This is because they can help clients to develop a realistic plan as they know their living condition better and they have more insights about clients’
symptoms besides clients themselves and clinician. They can also remind client if they do not adhere to the plan if they are clear about the plan. Therefore, it is important to involve them start from the development stage (Orum, 2008). 4) Step 3: Making a wellbeing plan - In this step, client must be the one who speak first and the most. Then only by the significant others as it should reflect their personal styles and preferences for the plan to work. Clinician will play the role to correct any misconception and provide appropriate suggestion for improvement (Orum, 2008). - Important component to be included in the plan: (a) Early warning signs of relapse (b) Risk factors that trigger the relapse (c) Appropriate method to be used when early warning signs are noticed by client and their significant others (including how feedbacks should be delivered especially when thy client does not adhere to plan, what make it difficult to be accepted and how to overcome the difficulties). (d) The method that client prefer significant others to use, what are the consequences that he/she is ready to face (including safety measures that will be taken and by whom). (e) Strategies that will be taken and commit to promote quality-of-life (especially when individuals are in depressive stage, by adopting the principles of positive psychology: recuperate, master basic management skills, commit to searching paths return to lifestyle that is engaging, pleasurable and meaningful). 4) Other important factors to be discussed during development of wellness plan (Orum, 2008):
BIPOLAR DISORDER
36
(a) Intervene at the earliest possible moment, therefore it is important to identify the very early warning signs and ways to improve mindfulness on it. (b) Take into account the strengths and weaknesses of close relationship with the significant others so that it can strengthen the effectiveness of help from significant others. (c) The goals should be graded and increase the difficulty bit by bit to maintain motivation and decrease the likelihood to trigger depressive episode (d) The plan needs to fit the person so that it increase commitment and thus likelihood of being effective (e) Benefits of collaborating with significant others should be discussed and appreciated to increase client perceived support and commitment in the plan G. FACTORS WHICH INFLUENCE CHOICE OF TREATMENT 1) Types of bipolar disorder (Parker, 2008; Yatham & Maj, 2010)
Bipolar I Bipolar II Cyclothymic
Psycho -education
IPSRT
CBT
FFT
Wellness plan
FFT
Wellness plan
2) Polarity of clients’ disorder (Miklowitz, 2008a)
Psycho -education
IPSRT
CBT
Manic Depressive (Note: IPSRT & CBT will only be effective for clients in manic/hypomanic episode if they are stable under medication). 3) Phases of disorders that clients are in (i.e acute, maintenance) (Miklowitz, 2008a)
Psycho -education
IPSRT
CBT
FFT
Wellness plan
Acute Maintenance (Note: (i) Psychoeducation (especially group 1 is more effective for clients in maintenance phase (ii) IPSRT will only be effective for clients in acute phase if they are stable under medication). 4) Cycling (i.e. rapid and typical)
Pilot study of Cognitive Behavioral Therapy found that CBT was able to reduce depressive symptoms in clients with rapid cycling (Relly-Harrington et al, 2007). 5) Pregnancy and Postpartum
Pregnancy of clients with is a sensitive period especially if they are in manic or depressive
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37
episodes, as medication can have serious effect on their fetus. Therefore, psychotherapy and psychoeducation play important roles in controlling symptoms in mother with Bipolar Disorder. (a) If client experience depressive episodes before giving birth, psychoeducation and interpersonal therapy have been found to be effective in reducing depressive symptoms (Spinelli, 1997 as cited in Frey et al., 2010). (b) Family-focused therapy may be helpful in educating family regarding bipolar disorders and assisting communication between pregnant client with family (Frey et al., 2010) (c) If client experience depressive episodes after giving birth, cognitive behavioral therapy has been found to be effective in reducing depressive symptoms (Applebly et al., 1997 as cited in Frey, et al., 2010). 6) Age
(a) Multifamily and individual psychoeducation, family-focused therapy, child and familyfocused CBT have been found to be effective in reducing symptoms and prevent relapse (Fristad, 2006; Miklowitz & Chang, 2008; West, Henry & Pavuluri, 2007 as cited in Carlson & Weller, 2008). (b) To date, there is less study on effectiveness of psychotherapy on elderly patient with Bipolar Disorder. However, in their study, Nguyen et al. (2007) found that CBT that specifically adjusted for older adults showed effectiveness in helping them to control symptom and prevent relapse (Richardson, 2010). 7) Comorbidity
(a) Cognitive Behavioral Therapy has been shown to be effective in treating Bipolar Disorder that is comorbid with anxiety (El-Mallakh & Hollifield, 2008). (b) Integrated Group Therapy (IGT) has been found to be effective in addressing Bipolar Disorder with Substance Abuse, but mostly on substance abuse issues only (Weiss, 2004). 8) Risk of suicide
(a) Goldstein et al. (2007) found that Dialectical Behavior Therapy was effective in reducing suicide ideation in adolescents aged between 14-18 years old. (b) Miklowitz et al. (2009) found that Mindfulness Behavior Therapy was effective in decreasing suicide ideation in a group of individuals in middle adulthood. H. TREATMENT OF CHOICE
(a) Patients who took part in Interpersonal and Social Rhythm Therapy (IPSRT) have higher probability and take shorter time to recover compare to patients who received standard care (Miklowitz et al., 2007). In another study, patient who participated in IPSRT also showed longer symptoms-free period and able to regular daily routine better compared to patient who received intensive care management. (b) Patient who take part in CBT: (i) Take longer period for another relapse, lower mania scores, improved behavioural selfcontrol compared to control group (Lam et al., 2005). (ii) 60% of reduction rate & fewer hospitalization compared to the patients’ own history of relapse & hospitalization (Scott et al., 2001).
BIPOLAR DISORDER
38
(iii) In group CBT, clients who have cyclothymic showed significant decrease in depressive and manic symptoms compared to client in clinical management (CM) after 1 and 2 years treatment (Fava et al., 2011). (c) Patients who participated in psychoeducation: (i) showed improvement in symptoms, functioning and family attitudes after 18 months among inpatients with mood disorders (Clarkin et al., 1998). (ii) has their relapse being prevented, less constant rehospitalisation, shorter period of acute illness (Colom & Berk, 2010). (d) Participating in Family-Focused Therapy help patients to stabilizing their bipolar mood, delay recurrences and rehospitalisation, increase adherence to medication and improve their family relationship functioning (Miklowitz, 2010). (e) Patients who underwent DBT had significant improvement in regulation of emotions, symptoms and depression and less likely to engage in suicidal and self-harming behaviour compared to pre-treatment (Goldstein et al., 2007). (f) Patients who participated in Mindfulness-Based Cognitive Therapy (MBCT) had their depressive and anxiety symptoms being reduced (Williams et al., 2008), and reduced in suicide ideation (Miklowitz et al., 2009). I. SUCCESSFUL COMPLETION OF THERAPY
According to Hirschfeld et al. (2007), indicators of successful therapy is the sustained remission/recovery, which are: (a) Scoring in Youth Mania Rating Scales is equal or lower than 8 (b) Scoring in Hamilton Rating Scale for Depression is equal of lower than 7 (c) Scoring in Clinical Global Impression for Bipolar Disorder (severity) is equal or less than 2. (d) Global functioning return to the normal level similar to before relapse/having Bipolar Disorder, and can function normally without assistant from significant others. J. RECOMMENDATIONS FOR MAINTENANCE OF GAINS
1) Wellness plan proposed by Parker (2008) that has been discussed in intervention option can be used to help clients maintain what they have learned from psychotherapy and help regulate their emotion better. 2) Another method that can be acted as booster programme that encourage independence and ensure the maintenance is the implementation of Life Goal Collaborative Care Model (LGCC) (Kilbourne et al., 2008). 3) The self-management programme in LGCC (Bauer et al., 2001) aims to: (a) Increase their awareness of procedure to manage their physical and mental health condition. (b) Spark their motivation to change (c) Form skills and knowledge to manage health condition (d) Increase self-competency in maintaining and adhering to changes and follow up about improvement towards achieving goals. 3) In this programme (Bauer et al., 2001), clients will be in group and be taught about
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(a) Bipolar disorder (b) Coping strategies for manic and depressive symptoms through active discussion (c) How to increase self-efficacy without receiving support from others. (d) How to engage health care provider effectively in collaborative decision making. 4) To increase and maintain client’s motivation in following in the programme and self -
management, Motivational Enhancement counseling will be used (Bauer et al., 2001). 5) Another two important components of LGCC is the decision support, which provide information and guidelines in seeking proper help and support when necessary, and care management which coordinate healthcare service between clients and providers (Kilbourne et al., 2008). 6) The ultimate goal of this programme is to encourage independence and responsibility taking by clients, at the same let them know there are always someone ready to help them to overcome the chronicity of Bipolar Disorder.
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