The Rationale For Adjunctive Psychological Treatments

Bipolar disorder has a median age of onset in the mid-20s, but most individuals report that they experienced symptoms or problems up to 10 years before diagnosis. Thus, the early evolution of BP may impair the process of normal personality development or may mean that the person starts to employ maladaptive behaviours from adolescence onwards. Co-morbid anxiety disorders, including panic and post-traumatic stress disorder (PTSD) and other mental health problems are common accompaniments of BP and as many as 40% of subjects may have inter-episode sub-syndromal depression (Judd et al., 2002). Although many individuals manage to complete tertiary education and establish a career path, they may then experience loss of status or employment after repeated relapses. One year after an episode of BP, only 30 % of individuals have returned to their previous level of social and vocational functioning. Interpersonal relationships may be damaged or lost as a consequence of behaviours during a manic episode and/or the individual may struggle to overcome guilt or shame related to such acts. Thirty per cent to 50 % of individuals with BP also meet criteria for substance misuse or personality disorders, which usually predict poorer response to medication alone. Recent studies of clinical populations of BP identify that (like persons with chronic medical disorders such as diabetes, hypertension and epilepsy), 30 % to 50 % of individuals with BP do not adhere with prescribed prophylactic treatments. Furthermore, attitudes and beliefs about BP and its treatment explain a greater proportion of the variance in adherence behaviour than medication side-effects or practical problems with the treatment regime (Scott & Pope, 2002).

The above problems identify a need for general psychological support for an individual with BP. However, there is a difference between the general non-specific benefits of combined pharmacotherapy and psychotherapy and the unique indications for psychological interventions. For a specific psychological therapy to be indicated as an adjunct to medication in BP it is necessary to identify a psychological model of relapse that:

• Describes how psychological and social factors may be associated with episode onset. For example, social rhythm disrupting life events may precipitate BP relapse and so stabilizing social rhythms is a key additional element in interpersonal therapy as applied in BP.

• Provides a clear rationale for which interventions should be used in what particular set of circumstances. For example, the use of family focused therapy (FFT) is supported by research demonstrating that a negative affective style of interaction and high levels of expressed emotion in a family are associated with an increased risk of relapse in an individual with BP.

Systematic research is currently under way, exploring cognitive, behavioural, emotional and interpersonal aspects of BP. These psychological models can be integrated with the 'instability model of BP relapse' as proposed by Ehlers and colleagues (Ehlers, Frank & Kupfer, 1988) and promoted by Goodwin & Jamison (1990). Briefly stated, the instability model identifies that in individuals with biological vulnerability to BP, there are four basic mechanisms of relapse and each mechanism is associated with biological dysregulation (neurotransmitter or neuroendocrine disturbances), and each mechanism is hypothesized to act through the final common pathway of sleep disruption. As shown in Figure 18.1 (working from left to right) an individual may experience internal change in biological functioning that leads to the development of the early 'prodromal' symptoms of relapse. Second, medication non-adherence may destabilize their physical state. Third, disruption to regular social routines (alterations to meal times, erratic weekly schedules, changes to the sleep-wake cycle) may produce circadian rhythm dysregulation, leading to relapse. Fourth, life events with specific personal meaning for that individual (as described in Beck's cognitive model) may lead to stress that ultimately leads to biological dysregulation. Obviously,

Figure 18.1 The instability model of bipolar relapse.

family attitudes and interactions can 'stress' the individual's biological system via any of the last three pathways described. Likewise, an individual may engage in substance misuse as a consequence of specific beliefs and attitudes (pathway 4), or its impact may be directly via the third pathway.

Although this brief description is an oversimplification, the instability model is helpful when considering the potential use of psychological treatments. For example, where no external stressor is identified it may still be possible to teach the individual to recognize the key early warning signs (such as sleep disruption) of episode onset and instigate a cognitive-behavioural relapse prevention package (Perry et al., 1999). Psychoeducation and adherence therapy can be used to target the second pathway (Colom etal, 2003; Scott & Tacchi, 2002), interpersonal social rhythms therapy (IPSRT) can be used to stabilize circadian rhythms (Frank et al., 1994) whereas cognitive therapy (CT) mainly focuses on the fourth pathway (Lam, Bright, Jones et al., 2000; Scott, Garland & Moorhead, 2001). However, this is not to suggest that each therapy 'maps' exclusively onto one particular pathway; the boundaries between therapies are flexible and there are several common elements. For example, CT also addresses attitudes toward medication adherence and employs self-regulation techniques. Likewise, IPSRT explores an individual's understanding of BP and his or her beliefs about relationships or personal roles that may otherwise impair their functioning. Family therapy may also target a number of pathways simultaneously (Miklowitz et al., 2000), including malevolent interpretations and attributions.

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