Lacy Milonas

Bipolar: Diagnosis to Treatment

 

Bipolar (BD) is a manic-depressive disorder characterized by the presence of mood swings between manic or hypomanic episodes, and major depressive episodes. BD effects approximately 2.6% of the adult U.S. population, and approximately 1.8% of the

U.S. pediatric population (Halfon, Labelle, Cohen, Guilé, & Breton, 2013). Those suffering from BD are at an estimated 15-fold increased risk for suicide compared to those not afflicted by BD (Muralidharan, Kotwicki, Cowperthwait, & Craighead, 2015). Children and adolescents with BD are also at an elevated risk for suicide, being twice as likely than adolescents with major depression to attempt suicide (44.4 vs. 22.2%). One recent study researching prevalence of psychiatric disorders in adolescent suicides even found that of adolescent suicide completers, 18-22% presented with BD symptomology (Halfon, Labelle, Cohen, Guilé, & Breton, 2013).

In Bipolar Disorder, levels of insight vary as a function of the mood state and appear to influence pharmacology compliance, quality of life, the presence of suicidal ideations, and aggressive behavior (Silva, Mograbi, Silveira, Nunes, Novis, Landeira- Fernandez, & Cheniaux, 2015). Because different mood states so dramatically influence the individual’s symptomology, positive and negative affect, cognitive processes, and determine treatment efficacy, stabilizing the mood and maintaining a steady emotional and behavioral baseline is a critical component in treating BD.

 

Presentation

Bipolar is a manic-depressive disorder characterized by the presence of mood swings between manic or hypomanic episodes, and major depressive episodes. During the manic episode, the individual experiences abnormally and persistently elevated, expansive, or irritable mood, increased goal-directed activity or energy lasting at least one week and present most of every day (DSM-V, 2013). The hypomanic episode resembles the manic episode accept that its duration is only several days. During both manic and hypomanic episodes, the individual experiences at least three of the following symptoms including: inflated self-esteem or grandiosity, deceased need for sleep, flight of ideas, distractibility or psychomotor agitation, and increased engagement in risky behaviors, such as excessive spending or sexual indiscretions (DSM-V, 2013). The difference in Bipolar I and Bipolar II are distinguishable in the DSM-V (2013) by the presence of a manic episode in Bipolar I, which can often raises the level on acuity of the individual’s lifetime symptom experience. Either following or proceeding the manic or hypomanic episode, the major depressive episode is characterized by a period of two weeks which negatively impacted the individuals functioning during which five of the following symptoms occurred including: depressed mood most of the day every day, diminished interest in pleasurable activities, insomnia or hypersomnia, feelings of fatigue and worthlessness, thoughts of death, and inability concentrating (DSM-5, 2013).

Common in BD is the accompanying occurrence of psychotic features, which ought to be specified during diagnosis. Accompanying psychotic features may include both mood congruent and incongruent audio or visual hallucinations and delusions. BD may also present with anxious distress, as rapid cycling (with 4 or more mood episodes within a 12 month period), with catatonia, with atypical features, or with melancholic features.

Whereas negative affect is most commonly associated with mental health disorders, individuals with BD are more so affected by elevated levels of positive affect and hyper-arousal versus emotional lability. Individuals with BD struggle to down regulate emotion intensity and engage in emotion regulation strategies that prolong and intensify problematic positive mood states (Stanton, Gruber, & Watson, 2016), which is a an uncommon and comparably under-researched phenomenon in the field on mental health. BD can present more distinguishably than other disorders when it comes to diagnosis because mania and hypomania, which are unique to BD and very few other mental disorders, presents such increased level of positive affect, whereas other disorders are characterized by decreased positive affect and increased negative affect. This increased affect, therefore, is critical in evaluating during diagnostic assessment for possible BD. Cross cutting symptom measures are available to distinguish grandiose narcissism, depression, and schizophrenia, for example, by evaluating manic presentations compared to presence of depressive symptoms (Stanton, Gruber, & Watson, 2016) and activated positive affect.

When evaluating an individual for BD, it is also important to identify their current mood state. Those with BD can present in several different states including mania, mixed episode, depression, and euthymia. Different affective states will present different levels of insightfulness into their disease depending on the individual.

However, an individual in a state of mania or mixed episode is the least likely to benefit from treatment, as during this affectively elevated state the individual is the least likely to be aware of their own illness or accept therapeutic interventions. Research has shown that insight into BD is less compromised during depression and periods of euthymia (Silva, Mograbi, Silveira, Nunes, Novis, Landeira-Fernandez, & Cheniaux, 2015).

 

Etiology

Because BD is a highly hereditable illness, a positive family history in first- degree relatives is the strongest predictor of future illness, heredity rates being an estimated between 65-85% (Pavlickova, Turnbull, & Bentall, 2014). However, although studies have proven the genetic link between BD and hereditabiliy, there are still arguments as to how likely offspring are to develop BD versus to develop other less extreme psychopathology. Pavlickova, Turnbull, & Bentall (2014) found a 1997 study which claimed that up to 52% of offspring of parents with BD (compared to 29% in children of offspring of parents without BD) met criteria for psychopathology. However, in their own mixed method study, the authors found that psychopathology rates were only as high as 23%, which is substantially lower than previous reports.

It is widely accepted that poor quality of life, trauma, and adverse childhood experiences can predict and affect mental health disorders. Stress, be it socioeconomic, cultural, or related to stigma, violence, or loss of a loved one increases ones susceptibility for anxiety, depression, or other mental health problems, including BD. This perspective raises the argument that environmental and socio-cultural factors are also strong predictors for BD, possibly more so than genetics depending on the reader’s stance on nature versus nurture.  Pavlickova, Turnbull, & Bentall noted that although the risk for BD is often indexed as genetic, there is also a more immediate vulnerability that entails living with a parent who is anxious, often unstable, and extreme in their behaviors and specific style of thinking and interpreting the world (2014). It is therefore arguable that when evaluating an individual for BD, both familial history and past quality of life be factors in assessment.

Weather or not the individual genetically inherited BD or weather BD manifested from developed psychopathology, BD still negatively impacts the individuals chemical balance. Biochemical imbalances in the brain of the individual with BD cause euphoric highs during the manic stage of BD, and devastating lows during depressive episodes.

This imbalance cannot self-correct, meaning that mood swings continue to occur until psychotropic treatment is introduced. Psychologically, this can be difficult for the individual with BD to accept as, as previously mentioned, the individual may lack awareness of the illness due to their chemical imbalance blocking any insightfulness.

 

Treatment

Long-term treatment for BD focuses on preventions of manic and depressive episodes. Effective treatment for BD falls into two primary categories: psychotherapeutic and psychopharmacological. Within the psychotherapeutic category of treatment exists behavioral approach systems, family work for interrelational interventions, and Dialectical Behavioral Therapy (DBT), to name a few evidence-based practices, that effectively treat BD. Because BD is a disorder that affects the entire person (e.g. biochemically, occupationally, socially/relationally), treatment interventions are more effective when supports are in place to continue therapeutic interventions in the home and in the community. Hence, involving supportive family and friends whenever possible in treating BD is ideal.

Research indicates that family environments in an important contextual factor that influences the course of BD (Muralidharan, Kotwicki, Cowperthwait, & Craighead, 2015). Because of this, family based interventions comprising psychoeducation, communication skills training, and problem-solving skills are effective in reducing symptom severity and escalation severity. Because individuals with BD have cognitive styles marked by higher levels of perfectionism and self-criticism, and tend to have greater physiological and emotional reactivity to reward/non reward, the individual’s level of sensitivity to negative feedback is a risk factor when considering how parents and family approach or provide feedback to the individual with BD.

Muralidharan, Kotwicki, Cowperthwait, & Craighead (2015) found that frequent exposure to failure cures such as criticism from a family member may exacerbate BD symptoms and increase tendencies to deregulate (have mood swings). According to attachment theory, belief in the availability of support in times of need is essential to forming a healthy baseline, and that without this baseline, the individual will develop hasty approach tendencies in pursuit of achievements or rewards which will quickly oscillate to disengagement is response to failure cures.  Considering attachment theory and the former’s 2015 findings, it is likely that family interventions, through their building of positive communication, may also build warmth and attachment which will aid the individual with BD in learning to play a role in regulating their own emotions in a trusting and safe environment.

Fredman, Baucom, Boeding, & Miklowitz (2015) found that high levels of emotional engagement by family members in the form of unsolicited advice giving and promoting patient’s well-being ahead of one’s own might be reasonable in the context of severe and recurrent illness as it can lead the patient to feel validated, safe, and less criticized, which can exacerbate BD symptomology and help the escalated BD patient stabilize. Targeting communication skills and problem solving skills while decreasing criticism has shown to be the most effect familial interventions.  While previous research supports treating BD with psychotherapy and psychopharmacologic interventions, integrating family therapy has proven a more rapid recovery from manic and depressive episodes, and longer periods between recurrence than patients who did not receive family-focused therapy (Fredman, Baucom, Boeding, & Miklowitz, 2015). Furthermore, through psychoeducation, supports of the BD individual can become better equipped to recognize early signs of onsetting manic or depressive episodes.

Pharmacologic treatment of BD mostly consists of combinations of at least two drugs, including mood stabilizers (lithium and anticonvulsants), atypical antipsychotics, and antidepressants (Vieta, & Valentí, 2013). Antidepressants are the most widely prescribed psychopharmaceutical, however, there is little evidence supporting their efficacy in treating BD. Some evidence supports that fluoxetine may provide therapeutic relief in BD, but only in combination with olanzapine. Conversely, some evidence has also shown that the use of antidepressants in BD has been associated with increased risk of affective switching, higher risk for suicide, and increased risk for development of mixed states (Vieta, & Valentí, 2013).

Long-term management of BD with low-dose antipsychotics is a well-established practice due to proven clinical success rates. Olanzapine, Quetiapine, Rispiridone, and Aripiprazole are commonly used in conjunction with lithium or Lamotrigine as first line of maintenance treatment. Similarly to all other psychopharmaceuticals, these medications have different side effects, which affect each individual differently. The genetic component is also important in that different individuals will process their medications at different speeds depending on their genes. It is therefore important that each individual with BD have their medication closely managed, especially at the onset of BD, to find the combination of medications that are individually current for their unique physiological and genetic make-up.

Lithium has high success rates in reducing recurrences of manic and depressive episodes, up to 50% in some studies when used at optimum doses (Vieta, & Valentí, 2013). Lithium also has anti-suicide properties, independent from its relapse prevention properties. While Lithium is a good option for BD maintenance treatment, lithium also has negative side effects (polydipsia, nausea, fatigue) that cause some users to discontinue use. Lithium can also be dangerous, sometimes fatal, if overly consumed. Poor adherence to medication has an impact on both clinical and safety outcomes of BD patients, including and increased risk of episode relapse, suicide risk, and hospital readmission (Sylvia, Reilly-Harrington, Leon, Kansky, Calabrese, Bowden, Nierenberg, 2014). Because of the dangers of episode relapse from discontinued use, adhering to a medication regiment is critical with BD.

Adherence rates, however, are poor with patients with BD. Several factors have been identified for medication non-adherence including substance use, patients who are younger, are single or living alone, or had an earlier age of BD onset (Sylvia, Reilly- Harrington, Leon, Kansky, Calabrese, Bowden, Nierenberg, 2014). Other risk factors of medication non-adherence include prior suicide attempts, current anxiety disorder, side effects, rapid cycling, race, poor familial protective factors, and homelessness. The latter socio-cultural issues are prevalent when it comes to medication non-adherence because of lack of resources for lower socioeconomic individuals, lack of access to insurance or adequate providers, are poor public awareness and education. In short, poor medication- adherence is a mental health issue, but also an issue of social injustice.

It is important to note that while some providers advocate alternative medicines for mental health disorders such as foods that improve mood, exercise and yoga, aromatherapy, nutritional supplements, etc., evidence does not currently support the use of nutritional supplements in the treatment or prophylaxis of BD (Rakofsky, & Dunlop, 2014).

 

Clinical Integration

The writer recently treated a client, for the sake of this study will be called Wing. Wing was an 18-year-old Chinese American female who was adopted from China at the age of 10. Wing presented immediately after her most recent of multiple inpatient hospital admittances resulting from psychiatric disturbances. Wing presented with a diagnosis of Bipolar I with psychotic features, and developmental disability. Wing lived with her loving and supportive Caucasian parents of an upper socioeconomic status, and was well connected to her community and to therapeutic provides. Wing’s current medications included Aripiprizole, Lithium, Guanfacine, and Hydroxyzine.

Wing typically presented as well-oriented, with slightly delayed speech and motor functions, and normal eye contact.  Wing’s affect was typically euthymic and her behavior was cooperative. The writer noticed that Wing’s lips were frequently chapped and her skin was often flakey.  Wing’s activities of daily living (ADLs) were significantly impacted by BD in that Wing reported staying up all night every night and being tired during the day. Wing was also having trouble eating and was losing weight. Wing reported audio hallucinations at times, and suffered from an almost chronic state of paranoia. Wing was experiencing medication side effects including frequent nausea, polydipsia, fatigue.

The writer’s work with Wing only lasted 90 days, before Wing’s tier expired to remain under the writer’s care. During that time the writer provided in-home psychotherapy utilizing behavioral interventions and the therapeutic relationship as the base of their work. The writer coordinated care with Wing’s primary therapist, Wing’s psychologist, the Pediatric Behavioral Medicine Unit (PBMU), and Wing’s parents.

Working with Wing significantly influenced the writer’s understanding of BD and the impacts of medication non-adherence, medication side effects, and the presentations of BD during states of mania, depression, euthymia, and mixed episode in that previously the writer had little clinical exposure to sever or complex BD.

The above case example supports the research presented in this essay in that treatment in the case of Wing was only able to become effective after all avenues of support were incorporated into Wing’s treatment plan. Biologically, Wing required medication to prevent episodes of mania or depression. When Wing failed to adhere to her medication because of unwanted side effects or Wing’s perceptions that her supports did not care, Wing relapsed into states of mania or depression that led to being hospitalized. Only through therapeutic involvement of the family, psychoeducation, problem solving and communication based interventions, individual psychotherapy, and close medication management was Wing able to achieve some recovery and return to a healthy baseline.

 

Conclusion

BD is a highly multifaceted disorder that requires highly individualized treatment plans because of the complexities BD presents. Because of the varying mood states, tendencies to swing between states, need for medication, psychotherapy, and community or familial supports, BD is unique in the complications associated with treatment.  It is the writers hope that mental health providers continue to research mental health disorders in order to understand their individual complexities and therefore provide the best treatment at practitioners.

 

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM–5. Washington, D.C: American Psychiatric Association.

Fredman, S. J., Baucom, D. H., Boeding, S. E., & Miklowitz, D. J. (2015). Relatives’ emotional involvement moderates the effects of family therapy for bipolar disorder. Journal Of Consulting And Clinical Psychology, 83(1), 81-91. doi:10.1037/a0037713

Halfon, N., Labelle, R., Cohen, D., Guilé, J., & Breton, J. (2013). Juvenile bipolar disorder and suicidality: a review of the last 10 years of literature. European Child & Adolescent Psychiatry, 22(3), 139-151.

Muralidharan, A., Kotwicki, R. J., Cowperthwait, C., & Craighead, W. E. (2015).

Parental Relationships and Behavioral Approach System Dysregulation in Young Adults With Bipolar Disorder. Journal Of Clinical Psychology, 71(4), 387-401.

Pavlickova, H., Turnbull, O., & Bentall, R. P. (2014). Cognitive vulnerability to bipolar disorder in offspring of parents with bipolar disorder. British Journal Of Clinical Psychology, 53(4), 386-401.

Rakofsky, J. J., & Dunlop, B. W. (2014). REVIEW OF NUTRITIONAL SUPPLEMENTS FOR THE TREATMENT OF BIPOLAR DEPRESSION. Depression & Anxiety (1091-4269), 31(5), 379-390.

Sylvia, L. G., Reilly-Harrington, N. A., Leon, A. C., Kansky, C. I., Calabrese, J. R., Bowden, C. L., & … Nierenberg, A. A. (2014). Medication adherence in a comparative effectiveness trial for bipolar disorder. Acta Psychiatrica Scandinavica, 129(5), 359-365.

Silva, R., Mograbi, D., Silveira, L., Nunes, A., Novis, F., Landeira-Fernandez, J., & Cheniaux, E. (2015). Insight Across the Different Mood States of Bipolar Disorder. Psychiatric Quarterly, 86(3), 395-405.

Stanton, K., Gruber, J., & Watson, D. (2016). Basic Dimensions Defining Mania Risk: A Structural Approach. Psychological Assessment, doi:10.1037/pas0000337

Van Rheenen, T. E., & Rossell, S. L. (2013). Genetic and neurocognitive foundations of emotion abnormalities in bipolar disorder. Cognitive Neuropsychiatry, 18(3), 168- 207.

Vieta, E., & Valentí, M. (2013). Pharmacological Management of Bipolar Depression: Acute Treatment, Maintenance, and Prophylaxis. CNS Drugs, 27(7), 515-529.